Interactions between HIV/AIDS
and the Environment
A Review of the Evidence and Recommendations for Next Steps
International Union for Conservation of Nature - ESARO
Interactions between HIV/
AIDS and the Environment
A Review of the Evidence and Recommendations for Next Steps
Prepared by:
Susan Bolton1 and Anna Talman2
University of Washington
Seattle, Washington USA
For:
IUCN-ESARO and IPPF-ARO
Nairobi, Kenya
May 2010
Supported by:
1
2
School of Forest Resources, College of the Environment, sbolton@uw.edu
Department of Global Health, School of Public Health, atalman@gmail.com
i
Interactions between HIV/AIDS and the Environment
Published by:
IUCN ESARO Office, Nairobi, Kenya
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© 2010 International Union for Conservation of Nature and Natural
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Citation:
Bolton, S. and Talman, A. (2010). Interactions between HIV/
AIDS and the Environment: A Review of the Evidence and
Recommendations for Next Steps. Nairobi, Kenya: IUCN ESARO
Office. viii + 62pp.
ISBN:
978-2-8317-1269-7
Design and layout:
Gordon O. Arara
Available from:
IUCN - ESARO Publications Unit,
P. O. Box 68200 - 00200, Nairobi, Kenya
E-mail: info.esaro@iucn.org
ii
Interactions between HIV/AIDS and the Environment
Table of Contents
Acronym List........................................................................................................................ v
Acknowledgements............................................................................................................. vi
Executive Summary.............................................................................................................vii
Introduction.......................................................................................................................... 1
Goals.................................................................................................................................... 2
Objectives............................................................................................................................. 2
Literature Review.................................................................................................................. 3
Methods........................................................................................................................................... 3
Emerging Themes............................................................................................................................ 3
Food Insecurity......................................................................................................................................... 4
Natural Resource Use............................................................................................................................... 7
Agriculture and Land Use......................................................................................................................... 7
Fisheries Sector Practices........................................................................................................................ 9
Gender Issues......................................................................................................................................... 10
Orphans and Vulnerable Children........................................................................................................... 10
Migration................................................................................................................................................. 11
Crisis Situations...................................................................................................................................... 11
Climate Change...................................................................................................................................... 11
Impacts of Environmental Interventions on the HIV/AIDS Epidemic...................................................... 12
Workforce and Human Capacity Impacts of HIV/AIDS........................................................................... 13
Historical Perspective: IUCN-ESARO and IPPF-ARO Work on Environment—HIV/AIDS Linkages.......14
Integrated Interventions: What do they look like?.............................................................. 15
Definitions...................................................................................................................................... 16
Key Principles: Gender and Participation...................................................................................... 17
Types of Interventions for Addressing HIV/AIDS and the Environment......................................... 17
Facilitating policy and systems-level change......................................................................................... 17
Strengthening community institutions.................................................................................................... 19
Promoting interventions in sustainable natural resources management................................................ 20
Encouraging sustainable, environmentally friendly livelihoods............................................................... 21
Engaging in HIV/AIDS-specific programming at the community level.................................................... 23
Internal mainstreaming: workforce interventions at institutional level.................................................... 24
Avoiding Unintended Consequences:........................................................................................... 25
Strengths and Weaknesses of Intervention Practice.................................................................... 25
Knowledge Gaps................................................................................................................ 26
HIV/AIDS, Natural Resource Use, and Livelihoods Research Needs........................................... 27
Traditional medicine and natural resource use....................................................................................... 28
Socioeconomic effects, livelihoods, and coping strategies.................................................................... 28
Management, governance and markets................................................................................................. 29
Migration and land tenure....................................................................................................................... 29
Climate change-related research needs....................................................................................... 29
Health and transmission-related research needs......................................................................... 30
Issues of Scale.............................................................................................................................. 31
A Conceptual Framework for Linking HIV/AIDS and the Environment.............................. 32
Upstream Factors: Poverty, Gender Inequality, and Social Disruption......................................... 32
Coping Ability: The Key Factor................................................................................................................ 33
A Vicious Circle........................................................................................................................................ 33
Zooming In: Connections at the Individual Level.......................................................................... 34
Zooming Out: Connections to Global Environmental Change...................................................... 35
Institutional Effects of HIV/AIDS on Conservation/Environmental Organizations......................... 36
Tensions......................................................................................................................................... 36
iii
Interactions between HIV/AIDS and the Environment
The Way Forward: Recommendations............................................................................... 38
Recommendations Discussed at Collaborator’s Meeting, 5 March 2010..................................... 38
Priority Research Topics in Order of Interest.......................................................................................... 38
Intervention priorities.............................................................................................................................. 38
Recommendations from Literature Review and Site Visits in Kenya............................................ 39
Monitoring and Evaluation is Critical...................................................................................................... 39
Additional Research Recommendations................................................................................................. 41
Additional Intervention Recommendations............................................................................................. 41
Integrating Interventions is a Process..................................................................................................... 41
Summary and Conclusions................................................................................................ 43
Bibliography....................................................................................................................... 44
Appendix 1: Selected Annotated Bibliography.................................................................. 51
List of Figures
Figure 1: Linkages between HIV/AIDS and the environment at the community level........................32
Figure 2: Linkages between HIV/AIDS and the environment at the household level.........................34
Figure 3: Effects of climate change on the links between HIV/AIDS and the environment...............35
Figure 4: Institutional level linkages between HIV/AIDS and the environment within
conservation/environmental organizations......................................................................... 36
List of Tables
Table 1: Types and numbers of publications reviewed........................................................................ 3
Table 2: Selected studies addressing connections between HIV, mortality,
and natural resource use........................................................................................................ 5
Table 3: Cross-sectoral issues addressed by the Millennium Village Project in Sauri, Kenya........... 19
Table 4: Internal mainstreaming activities for HIV/AIDS at two conservation organizations.............. 24
Table 5: A framework for integration of environmental and health programming.............................. 42
iv
Interactions between HIV/AIDS and the Environment
List of Acronyms
ABCG................ African Biodiversity Collaborative Group
AIDS.................. Acquired Immune Deficiency Syndrome
ARO................... Africa Regional Office
ARV.................... Anti-retroviral (medication)
CBNRM............. Community-Based Natural Resource Management
CBO................... Community Based Organization
ESARO.............. Eastern and Southern Africa Regional Office
EKZNW.............. Ezemvelo KwaZulu Natal Wildlife
FAO.................... United Nations Food and Agriculture Organization
GO..................... Governmental Organization
HELI................... Health and Environment Linkages Initiative
HIV..................... Human Immunodeficiency Virus
IGA..................... Income Generating Activity
IPPF................... International Planned Parenthood Federation
IUCN.................. International Union for the Conservation of Nature
MDG.................. Millennium Development Goal
M&E................... Monitoring and Evaluation
NCAPD.............. National Coordinating Agency for Population and Development (Kenya)
NGO.................. Non-governmental Organization
OVC................... Orphan and Vulnerable Child(ren)
PLWHA.............. People Living with HIV/AIDS
PRB................... Population Reference Bureau
SCC................... Swedish Cooperative Centre
UNAIDS............. United Nations Joint Programme on HIV/AIDS
UNDP................ United Nations Development Programme
UNEP................. United Nations Environment Programme
USAID................ United States Agency for International Development
UW..................... University of Washington
VCT.................... Voluntary Counseling and Testing (for HIV)
WEHAB.............. Water, Energy, Health, Agriculture, and Biodiversity
WESM................ Wildlife and Environmental Society of Malawi
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Interactions between HIV/AIDS and the Environment
Acknowledgements
This report would have been impossible without the intellectual and financial support of a number
of organizations and individuals. We would like to thank International Union for the Conservation
of Nature-Eastern and Southern Africa Regional Office (IUCN-ESARO) and International Planned
Parenthood Federation Africa Regional Office (IPPF-ARO) in particular for their financial and
logistical support of this endeavor. At the University of Washington, the Department of Global
Health, College of the Environment, and School of Forest Resources also merit recognition for
financial and logistical support. In Kenya, we met with representatives from University of Nairobi,
Swedish Cooperative Centre/VI Agroforestry, Family Health Options Kenya, Kenya Medical
Research Institute (KEMRI), Jiw Pachi HIV/AIDS Organization, and Kounkuey Design Initiative,
who were enthusiastic and very helpful in providing on-the-ground context for our literature
review. A number of individuals have been instrumental in helping this project get off the ground.
We would especially like to thank Judd Walson, Judy Wasserheit, Tom Hinckley, Ben Piper, and
Richard Fenske from University of Washington, Jonathan Davies, Claire Ogali, and Ben Wandago
from IUCN-ESARO, Lawrence Oteba from IPPF, Phillip Wambua, Bernard Washika and Wangu
Mutua from Swedish Cooperative Centre/VI Agroforestry, and Francis Mwaura from University of
Nairobi for sharing their time and knowledge with us. Thanks are also given to all participants in
the collaborators meeting held at IUCN-ESARO 5 March 2010 for their insight and enthusiasm.
Likewise, ideas from the Thika Women’s Group, Mitumba Youth Group, Aluor Widow’s Group, Orian
Comprehensive Care Clinic, Paro One Support Group, and Oogo Village PLWHA Group, and the
Kisumu LLIN Support Group were invaluable.
vi
Interactions between HIV/AIDS and the Environment
Executive Summary
Humans and other species rely upon natural ecosystem processes and ecosystem services for
their very survival. As the human population has grown, overuse or misuse of the environment and
impairment of its ability to provide ecosystems services have led to shortages in critical human and
other species needs. The last 10 years have seen an increase in the awareness of and interest in the
complex interactions among population, health and the environment (PHE) and even more recently,
an increase in awareness of linkages between HIV/AIDS and the environment, which could be
considered as a subfield under the umbrella of PHE. Recent studies have brought to light a series of
interacting and complex relationships, many with negative feedback loops, between HIV/AIDS and
the environment. A comprehensive examination of these relationships and analyses of the quality
and breadth of the evidence are lacking. We undertook a broad review of the published literature
regarding the potential links between HIV/AIDS and the environment to assess the evidence for
these connections and to provide guidance for possible next steps in addressing them through
basic or operations research and intervention.
The connections between HIV/AIDS and the environment are complex, multifactoral, bi-directional,
and involve indirect as well as direct pathways. In assessing the literature, we identified a number of
topics linking HIV/AIDS and the environment. Some of the most important themes connecting the two
are: food insecurity, natural resource use, agriculture and land tenure and use, the fisheries sector,
gender issues, orphans and vulnerable children, migration, crisis situations, climate change, effects of
environmental interventions on HIV/AIDS, and workforce and human capacity impacts of HIV/AIDS.
After evaluating the literature, we developed a conceptual framework (see Figures 1-4) for illustrating
the complex interactions between HIV and the environment. Based on the tenets of prevention from
the health arena and of addressing causal factors (ultimate) rather than symptoms (proximate) in the
environmental literature, we have identified three major upstream factors that affect all aspects of
the HIV/AIDS-environment nexus: social disruption, poverty and gender inequality. Poverty, gender
inequality, and social conflict set the stage for enhanced susceptibility to HIV and the increased
reliance on ‘free’ ecosystem services and biodiversity to meet increasing household needs that arise
from having to cope with the effects of HIV/AIDS. We consider poverty to be the keystone of these
three factors, that is, the factor which if altered will propagate the most important effects throughout
the system. We define poverty in the broadest terms, not just as lack of money but also as the lack
of access to information and resources with which to address basic human needs.
Coping ability is a linchpin in the pathway from poverty, gender inequality, and social disruption to
HIV. Coping ability is affected by social and individual capital and reflects economic, psychosocial
and physical resilience to adverse events. It is a key step mediating the role of upstream factors on
the downstream effects of HIV infection, increased reliance on natural resources, and environmental
degradation. Decreased coping ability makes people and communities more vulnerable to HIV/
AIDS. HIV/AIDS in turn leads to increased dependence on natural resources, as households lose
labor force, land tenure, and traditional knowledge, and are less able to maintain their previous
livelihoods. This increased reliance on natural resources in turn makes communities even less able
to cope, as they become more and more exposed to the vagaries of nature, weather, and availability
of resources. Infection with HIV/AIDS also itself decreases coping ability, which may lead to both
behavior that increases HIV transmission and also increased natural resource use. The cycle is
self-reinforcing and reciprocal. The effects of climate change will further weaken communities’ and
households’ coping ability, predisposing them to HIV vulnerability, risk behaviors, and infection.
To identify next steps in addressing HIV/AIDS and the environment, we evaluated strengths and
weakness of the evidence related to interventions and knowledge of the interactions between HIV/
AIDS and the environment. While it is clear that there is growing interest in mainstreaming and
addressing HIV/AIDS and the environment in an integrated, multisectoral fashion, specific evidence
regarding the success of interventions is still lacking. Monitoring and evaluation of conditions and/or
outcomes is a critical concern for implementing interventions, and has too often been overlooked. In
the research arena, the most glaring lack of evidence is studies that have a longitudinal focus with
vii
Interactions between HIV/AIDS and the Environment
repeated measures over several years, but research using comparison groups or randomization is
also lacking. Snapshot information gives a quick glimpse of issues, but without long-term followup the view is likely distorted, especially when dealing with ecological, health-related, and socioeconomic conditions that are in a state of flux. With respect to natural resources use, there is much
agreement as to the pathways through which HIV/AIDS can result in overuse and damage of various
resources such as timber and medicinal plants. What is conspicuously lacking is documentation
of status and trends of the various natural resources and of the extent of use by HIV/AIDS affected
households vs. poor households in general or those affected by other chronic diseases. Similar
issues exist in the broader environmental arenas of the agricultural, livestock and fisheries sectors.
A meeting in Kenya between academic researchers and health and environment sector
professionals resulted in the following research and action priorities.
•
Compare prevalence and interactions between HIV/AIDS and the environment across
different types of conservation areas to produce evidence supporting addressing HIV and the
environment as an integrated topic.
•
Identify relationships between environmental condition and HIV/AIDS prevalence. Do high
quality environmental conditions and availability or unavailability of natural resources correlate
with reduced prevalence of HIV/AIDS?
•
Create a viable and active collaborative group with a designated coordinator to facilitate
integration between health and environment sectors, disseminate information, and keep
interested parties informed of activities and advances in the HIV/Environment arena.
•
Conduct efficacy, effectiveness and operations research on existing models of implementing
integrated HIV/environment interventions seeking evidence-based practical interventions for
scaling up and disseminating.
Additionally we want to emphasize the following for future interventions and research:
•
Incorporate better and more extensive monitoring and evaluation of all projects,
•
Determine the interrelationships between HIV/AIDS and the upstream determinants of social
conflict, poverty and gender inequality in terms of their effects on ecosystems, ecosystem
services and natural resource use. Insofar as possible, address upstream factors with every
intervention.
•
Identify and measure appropriate ecological indicators to identify status and trends of critical
resources affected by HIV/AIDS.
•
Create inventories of known medicinal plants to track changes in numbers of plants and
identify areas needing protection to avoid extirpation.
•
Pursue additional pharmaceutical and clinical research regarding the effects of medicinal
plants and their interactions with ART.
•
Investigate the relationship between food insecurity and HIV/AIDS outcomes (for example,
clarify the relationship between food insecurity and the effectiveness of ART, susceptibility to
infection, and mother-to-child transmission).
•
Improve understanding of land use/land tenure issues. Collect additional data on site-,
gender-, age-, culture-specific uses of land and inheritance patterns.
•
Quantify and predict food insecurity and human health effects of climate change.
•
Build internal, national capacity for conducting research in developing countries.
•
Advocate for integration at the policy-level. Convince policy-makers that integration is an
important principle.
•
Mainstream HIV/AIDS at the institutional level and implement internal workforce-based
interventions.
viii
Introduction
Humans and other species rely upon natural
ecosystem processes and ecosystem services
for their very survival. Ecosystem services are
a necessary but not sufficient component of
human well-being (Butler and Oluoch-Kosura
2006). There are also cultural and social
aspects to human perceptions of well-being.
The Millennium Ecosystem Assessment (2005
cited in Confanlonieri and McMichael 2007)
lists general ecosystem services that provide
benefits to humans as provisioning services
such as clean air, clean water, food, new
products from biodiversity, regulation and
support services such as climate stability,
flood control, filtration of contaminants, and
also cultural services such as religious/sacred
sites and leisure. As the human population has
grown, overuse or misuse of the environment
and impairment of its ability to provide
ecosystems services have led to shortages in
critical human and other species needs. The
specter of climate change increases concerns
about sustainability and integrity of health or
well-being of biophysical and human systems
(Ahmed et al. 2009; Besada and Sewankambo
2009; Bloem et al. 2010; Costello et al. 2009;
Daily and Ehrlich 1996; Frumkin and McMichael
2008; McMichael et al. 2008a; McMichael et
al. 2003; Myers and Patz 2009; Ramin and
McMichael 2009; Tang et al. 2009; UNICEF
Innocenti Research Centre 2008). Many
authors have commented on the complex
interactions between human well-being and the
natural environment e.g., (Costanza et al. 2007;
Kasperson and Dow 2005; Levy et al. 2005;
McMichael et al. 2008b; Pimentel et al. 2007).
Millennium Development
Goals
Goal 1—Eradicate Extreme Poverty and
Hunger
Goal 2—Achieve Universal Primary
Education
Goal 3—Promote Gender Equality and
Empower Women
Goal 4—Reduce Child Mortality
Goal 5—Improve Maternal Health
Goal 6—Combat HIV/AIDS, Malaria, and
other Diseases
Goal 7—Ensure Environmental
Sustainability
Goal 8—Develop a Global Partnership for
Development
eight Millenium Development Goals (MDG)
(Mwaura 2007) that seek to make substantial
gains towards improving the lives of the
world’s disadvantaged people by 2015.
One weakness of itemizing the 8 MDGs
(listed below) is that many of the goals are
interlinked, and goal 7 (“Ensure environmental
sustainablity”) is critical to the success of
most of the others (Pisupati and Warner 2003;
Sachs et al. 2009).
Even though integrated population, health
and environment (PHE) community-based
projects have existed for over 30 years
(Finn 2007), the last 10 years have seen an
increase in the awareness of and interest in
the complex interactions among population,
health and the environment. Global institutions
have initiated various large-scale initiatives
to address these issues such as the WEHAB
Initiative (Water, Energy, Health, Agriculture,
and Biodiversity) that emerged from the 2002
World Summit on Sustainable Development
in Johannesburg, South Africa, and HELI
(Health and Environment Linkages Initiative),
begun by the World Health Organization and
the United Nations Environment Program.
WEHAB provides the framework for the
Millennium Development Goal 6 is to combat
HIV/AIDS, malaria, and other diseases. The
HIV/AIDS pandemic has had a tremendous
effect on populations and economies
throughout the world. UNAIDS estimates
that 33.4 million people were living with
HIV in 2008, and 2.0 million died of AIDS
complications that year. The vast majority
of people affected by the virus are living in
sub-Sarahan Africa, where 22.4 million are
infected, and adult prevalence is estimated
at 5.2%, though prevalence varies widely by
region, with national rates ranging between
1% and more than 25% on the continent
(UNAIDS and Organization 2009).
1
Interactions between HIV/AIDS and the Environment
Goals
There has been an increase in awareness
of linkages between HIV/AIDS and the
environment in the past few years. The
arena of HIV/AIDS and the environment
could be considered as a subfield under the
umbrella of PHE. One might ask, what does
HIV/AIDS have to do with the environment
and vice versa? Recent studies have
brought to light a series of interacting and
complex relationships, many with negative
feedback loops, between HIV/AIDS and
the environment. The International Union
for the Conservation on Nature (IUCN), the
International Planned Parenthood Federation
(IPPF) and others have funded workshops and
reports on the relationships between HIV/AIDS
and the environment in Eastern Africa (IUCNIPPF-IRDC 2008; IUCN 2008a; IUCN 2008b;
IUCN 2009; IUCN and IPPF 2009; Matiru and
Osur 2008; Mvoyi et al. 2008; Mwakitwange
and Bashemererwa 2008; Nakangu et al.
2008; Tassew 2008; Torell et al. 2007; Torell et
al. 2006; Tumwine 2007).
This report incorporates the findings of a
literature review, including International Union
for the Conservation of Nature Eastern and
Southern Regional Office (IUCN-ESARO)
and International Planned Parenthood
Federation Africa Regional Office (IPPF-ARO)
reports and other documents, a summary of
discussions with professionals from IUCN,
IPPF, the University of Nairobi (UoN), East
African Wildlife Society, Swedish Cooperative
Centre (SCC)/VI Agroforestry, Family Health
Options Kenya (FHOK), and the University of
Washington (UW), and results of field trips
to provide the authors with urban and rural
context to the problem in Kenya.
The goal of this report is to identify next steps
towards addressing issues associated with
HIV/AIDS and the environment. We will identify
the strength of evidence from existing surveys,
studies, and projects and suggest ways, where
necessary, to strengthen this evidence. The
primary aim is to produce convincing evidencebased data to enable policy makers at both
the institutional and governmental levels to
view HIV/AIDS through a broader lens and to
implement interventions that can effectively
address interactions between HIV/AIDS and
the environment.
Although on-the-ground circumstances make
it difficult to know exactly how the disease
affects the environment or vice versa, it is
clear that people are changing their behavior
in response to the pandemic. These changes
go well beyond the realm of sexual behavior
to affect coping decisions that change the
access, use, and management of natural
resources to secure individual, family, and
community livelihoods (Frank and Unruh
2008). HIV/AIDS is thought to lead to overuse
of natural resources, loss of traditional
knowledge, loss of human capacity and labor,
increased vulnerability of community-based
natural resources management and diversion
of conservation funds to meet HIV/AIDS-related
costs (Torell et al. 2006).
Objectives
The focus of most HIV/AIDS research and
programs has been on prevention and
treatment, with an emphasis on behavior
modification. This narrow focus excludes
the broader context of the disease and
ignores some of the more ultimate, rather
than proximate causes of the epidemic
(Stillwaggon 2006). Poverty, gender inequality,
and social conflict set the stage for enhanced
susceptibility to HIV and the increased
reliance on ‘free’ ecosystem services and
biodiversity to meet increasing household
needs that arising form having to cope with
the effects of HIV/AIDS.
2
•
Synthesize the literature on issues
associated with HIV/AIDS and the
environment
•
Identify and discuss examples of
interventions to address HIV/AIDS
and the environment
•
Identify data and knowledge gaps
•
Develop a conceptual framework to
address the links between HIV/AIDS
and the environment
•
Suggest next steps for basic and
operational research and for improving
integrated interventions
Interactions between HIV/AIDS and the Environment
Literature Review
Keyword searches of online databases using
Web of Science ISI, PubMed, and Google
Scholar, as well as snowball methodology
using the citations from each article reviewed,
were used to find relevant literature. We also
searched the websites of governmental,
inter-governmental, and non-governmental
agencies for related publications. IUCNESARO, IPPF-ARO, and National Coordinating
Agency for Population and Development of
Kenya (NCAPD) and Population Reference
Bureau (PRB) also furnished reports and
workshop proceedings, while collaborators at
UW and UoN provided papers and materials
for review. Key word searches included
various combinations of the following terms:
(HIV, AIDS, environment, natural resource
management/use, agriculture, conservation,
Africa, ecology, health, climate change,
integrated, multisectoral).
Methods
We conducted a review of the literature to
identify potential linkages between HIV/AIDS
and the environment; the review includes
documents from peer-reviewed journals,
government, inter-government, and nongovernmental agency reports, policy papers,
and other documents, including materials
available on the Internet. The search also
included climate change effects on human
health. It is important to note that this was not
a detailed systematic review; we believe that
we captured a representative, if not complete,
sample of literature regarding HIV/AIDS
and the environment. A selected annotated
bibliography of the most relevant papers is
included as Appendix 1.
This report focuses on sub-Saharan east Africa,
but similar concerns about HIV/AIDS and the
environment are arising globally, especially in
rapidly developing regions of Asia, in small,
developing nation-state islands (Hunter et al.
2008a) and in other parts of Africa, especially
west Africa (Dwasi 2002).
Table 1: Types and numbers of publications reviewed
Type of Publication
No.
In Peer-Reviewed Journals:
Original Research
39
Review Article
28
Case Study
9
Commentary
10
Policy Paper
4
Subtotal
The literature review captured a total of 177
relevant papers, reports, studies, and other
materials. Table 1 details the types and
numbers of publications reviewed.
Emerging Themes
90
The connections between HIV/AIDS and
the environment are complex, multifactoral,
bi-directional, and involve indirect as well as
direct pathways. Complex cycles of interaction
are everywhere. A number of themes emerged
repeatedly in the literature, highlighting the
most important types of interactions between
the HIV/AIDS epidemic and the environment.
In Sources other than Peer-Reviewed Journals
Review Paper 33
Policy Paper
14
Presentation, Conference,
or Workshop Paper
15
Published Guidelines or Tool-kit
11
Large Scale Demographic/
Health Survey
6
Case Study Paper
5
Thesis/Dissertation
2
Published Book
1
Subtotal
Grand Total
HIV transmission is often perceived as a
consequence of human behaviors: unprotected
sex, injection drug use, sharing needles.
However, it is also important to note that
much of the transmission in sub-Saharan
occurs between stable heterosexual couples
and through mother-to-child transmission.
While transmission risk behaviors are, in fact,
necessary for HIV-infection, it is important to
note that these behaviors occur in context, that
they are “conditioned by their environment”
87
177
3
Interactions between HIV/AIDS and the Environment
(Stillwaggon, 2006: 219). HIV/AIDS flourishes
in conditions of underdevelopment—food
insecurity, poverty, social inequity, unequal
power relations between the genders, poor
access to health services and substandard
infrastructure. People living in sub-Saharan
Africa face myriad risks that burden them
with a host of diseases. In the context of
poverty, malnutrition, high prevalence of coinfections with other infectious diseases, and
overburdened health systems, individuals may
be more susceptible to acquiring HIV and less
able to cope with HIV-related illnesses, both
physically and economically. Eileen Stillwaggon
(2006:69) writes,
Major Themes Linking HIV/AIDS
and the Environment:
“The HIV/AIDS epidemic in subSaharan Africa is not an isolated
phenomenon. It is a predictable
outcome of an environment of
poverty, worsening nutrition, chronic
parasite infection, and limited
access to medical care. In such
circumstances, people are more
susceptible to all infectious diseases,
no matter how they are transmitted…
Prevalence of HIV in Africa is not a
special case but a brutal indicator
of the nutritional, infectious, and
parasitic diseases that have afflicted
African people all along.”
• Effects of environmental interventions on
HIV/AIDS
• Food insecurity
• Natural resource use
• Agriculture and land use
• Fisheries sector practice
• Gender inequality
• Orphans and vulnerable children
• Migration
• Crisis situations
• Climate change
• Workforce and human capacity impacts of
HIV/AIDS
It is with this broad perspective on HIV as an
infectious disease determined by more than
simply “risk behaviors,” and with an equally
broad definition of “environment,” that we
examine the connections between the two.
For the purposes of this report, we define
environment as encompassing agriculture,
fisheries, protected areas, natural resources,
land use, and conservation.
Food Insecurity
Food insecurity is a linchpin in examining the
connections between the environment and
HIV/AIDS. Malnourished individuals are more
susceptible to HIV infection, and tend to have
worse outcomes once they are infected with
HIV (Anema et al. 2009) and in order to feed
themselves or their families may be more
likely to engage in risk behaviors. There is
growing evidence that antiretroviral treatment
itself may be less effective in persons with
inadequate nutrition (Anema et al. 2009;
Bloem et al. 2010). The relationship between
food insecurity and HIV/AIDS is, in fact,
vicious; households affected by HIV/AIDS are
subsequently less likely—because of loss of
labor productivity, increased expenditure on
treatment, etc.—to have adequate supplies of
food (Kaschula 2008), and are more likely to
consume fewer nutrient-rich foods (Onyango
et al. 2009), increasing levels of malnutrition at
the household level. Gillespie (2005) presents
a detailed review of the relationships between
HIV/AIDS and food insecurity.
4
5
Tanzania
Eastern and
Southern
Africa
South Africa
Dwasi, J
2002
Hunter, LM
et al.
2008
Global
Challe, JFX and
L Price
2009
Bryant, L et al.
2009
Forest products
Malawi,
Mozambique
Barany, ME et
al. 2005
Key informant interviews, focus
groups; Participatory Rural
Appraisal (PRA) methods;
qualitative and quantitative
analysis
Literature review, theoretical
analysis of role of forest
products in rural livelihoods;
research proposal
Methodology
Interviews (n=224), statistical
comparisons of groups
Fuelwood, water
District-level demographic
survey, household survey
(n=241)
Medicinal plants, Key-informant interviews
timber, wildlife
Endangered
edible orchids
Generalized
Analysis of National Adaptation
natural resources Programs of Action submitted
to the Global Environment
Facility for funding
Forest products
Sub-Saharan
Africa
Barany, ME
2003
Natural Resource
Consumed
Location
Paper, Year
Findings Regarding Link to HIV
Households affected by mortality and impoverished households more
likely to depend on natural resources. Changes in “selection, use, level
of consumption, and acquisition” of natural resources were observed.
Traditional medical practitioners and HIV/AIDS patients have
increased harvesting of plants and wildlife thought to be “cures” for
HIV, as well as timber. Parks staff says the harvesting is detrimental
and unsustainable.
HIV-affected people, especially orphans, were as much as 10 times
more likely to increase natural resource use. Orchid gathers noticed a
decline in the availability of most of the species collected.
Food insecurity and demographic pressures (not HIV per se) leads to
increased natural resource use.
Adult mortality or illness increased use of traditional medicines and
other forest products. 77% of affected households had made collection
trips in the previous 18 months. Affected households five times more
likely to collect fuelwood than unaffected households. Quality of
natural resources negatively correlated with HIV prevalence.
Natural resource use observed as both a short-term coping strategy
and a longer-term livelihood strategy among HIV-affected households.
Because food insecure, impoverished households have previously been
observed to depend on natural resources, it follows that HIV-affected
households will be more likely to depend on them.
Table 2: Selected studies addressing connections between HIV, mortality, and natural resource use
Interactions between HIV/AIDS and the Environment
Wild foods
South Africa
South Africa
Malawi
South Africa
Namibia
Hunter, LM
et al.
2007
Kaschula, SA
2008
Mauambeta, DC
2003
McGarry,
DK and C
Shackleton
2009
Ngwenya, BN
and K Mosepele
2007
Ngwenya, BN
and D Kgathi
2006
Dietary recall surveys
Household surveys (n=241) and
qualitative interviews (n=31)
Methodology
6
Families caring for symptomatic HIV-patients used 20-80 additional
liters of water per day, depending on type and severity of symptoms
(e.g. diarrhea).
Surveys
Case studies
Potable water
Drylands forest
products
Wood, medicine, Field study including interviews, AIDS contributes to an accelerated rate of natural resource extraction
focus groups, and Participatory
wildlife
Rural Appraisal (PRA) methods
Namibia
South Africa
Tanzania
Shackleton, CM
et al. 2007
Torell, E et al.
2006
HIV’s effects on labor and livelihoods have exacerbated peoples’
dependence on forests. Across Southern Africa, forests provide 4 –
30% of household income.
Fisheries act as a “safety net” for HIV/AIDS-affected families,
mitigating effects of chronic poverty.
Surveys and questionnaires
High-HIV-vulnerability children hunted for and ate more wild foods,
but impact on local fauna “unclear.” Two instances of capture of
IUCN “red list” species were noted, however.
Animal numbers have decreased, and poaching and collection of
timber for coffins has increased; park officials say this is related to
HIV epidemic.
AIDS-affected and orphan-fostering households were more foodinsecure and more likely to use wild foods, but may decrease their wild
food consumption because of labor and stigma concerns. Households
using wild foods tended to be more economically resilient.
Household mortality decreases food security, but not uniformly—the
gender of the deceased and the previous socio-economic status are
important. Dependence on wild foods is not only a short-term coping
strategy; it persists long after household shocks.
Findings Regarding Link to HIV
Fisheries
Mainly anecdotal; some
Timber for
interviews with park personnel;
coffins and
charcoal making, animal counts
wildlife
Interviews and food diaries,
Wild foods,
statistical analysis
including bush
meat
Wild foods
Natural Resource
Consumed
Location
Paper, Year
Table 2: Selected studies addressing connections between HIV, mortality, and natural resource use (contd.)
Interactions between HIV/AIDS and the Environment
Interactions between HIV/AIDS and the Environment
Food insecurity is an unfortunate reality in
much of sub-Saharan Africa. In 2008, the UN
Food and Agriculture Organization calculated
that 923 million people were undernourished
globally; this is an increase of about 75
million people from 2005 (Anema et al. 2009).
Women—both HIV-infected and uninfected—
are more frequently affected by food insecurity
globally (Anema et al. 2009). In one HIVtreatment facility in Kenya between 20 and
40% of the treatment cohort was malnourished
(Mamlin et al. 2009). Women are more prone to
nutritional deficiencies because of their unique
nutritional needs, especially when they are
pregnant or breastfeeding, and some cultures
have household food hierarchies. In most
of sub-Saharan Africa, women have higher
work loads yet consume fewer calories due to
cultural practices that favor men (FAO 2001,
accessed 2010).
of the relationship between the HIV/AIDS
epidemic and natural resource use.
There is some speculation that increased
dependence on natural resources by families
affected by HIV/AIDS will lead to overharvesting of certain species, degradation
of the environment, and a decrease in
biodiversity. One study in southern Africa
noted that the quality and availability of
natural resources (in this case fuel wood)
appears to be negatively correlated with
HIV prevalence (Barany et al. 2005).
Others note anecdotally that gatherers of
natural resources have noticed a decline
in prevalence, quality, predictability, or
accessibility of the products (Challe and
Price 2009; Dwasi 2002; Mauambeta
2003). Nonetheless, few papers address
the environmental/ecosystem impacts of
natural resource use, and even studies that
address these effects maintain that the
effect is “unclear” (McGarry and Shackleton
2009). A feature that is notably missing is
quantification of the use of natural resources.
Natural Resource Use
Food insecure or impoverished households
are considerably more likely to be affected by
HIV and the resultant high mortality of AIDS
(Barany 2003). These families are also more
likely to depend on natural resources as a
safety net (Andrew et al. 2003; Torell et al.
2006). Vulnerable families depend on the local
environment for a number of different types of
natural resources, including wild foods (plants
and bush meat), natural water sources for
consumption, washing, and household use,
traditional plant and animal medicines, timber
for building and coffin-making, raw materials
for craft-making, and fuelwood or burning
material for direct cooking and heating or
conversion to charcoal. Natural resources
are a “safety net” for families when HIV/AIDS
and/or poverty restrict(s) them from otherwise
maintaining a livelihood. Natural resource
collection is generally less labor-intensive
than agriculture, and requires little to no
start-up capital (Barany 2003). This effect is
observed elsewhere; impoverished families in
Brazil have also been observed to use natural
resources as a form of “natural insurance”
(Pattanayak and Sills 2001).
Agriculture and Land Use
In addition to contributing to a reported
increase in natural resource usage, the HIV/
AIDS epidemic has contributed to a substantial
reported change in land use practices (Barnett
et al. 1995; Drimie 2003). Because HIV/AIDS
primarily affects individuals during their most
productive wage earning period (people of
working age between 18 and 45), illness
and mortality from AIDS results in a labor
shortage at the household level (e.g., Barany
2003; Parker et al. 2009; Torell et al. 2006).
Though other factors, including drought, land
degradation, crop disease, and a host of
other issues also affect productivity and land
use, it is interesting to note that a decrease
in crop production has been observed
since the beginning of the epidemic in subSaharan Africa (Barany 2003; Barnett et al.
1995). Transitions to lower labor-intensity
farming techniques, to increased leasing or
sharecropping of land, and even to increased
fallowing of productive land have been
observed (Barany 2003; Du Guerny and Hsu
2004). At the community level, increased
mortality is negatively associated with the
amount of land cultivated (Barnett et al. 1995;
Jayne et al. 2006). Losses to community
productivity and ability to cultivate land appear
A number of studies have addressed the
connections between HIV infection, household
mortality, and natural resource exploitation.
Table 2 highlights the relevant findings of these
papers. Both Barany (2003) and Ternström
(2005) provide good case studies and reviews
7
Examples of Possible Impacts and Responses to HIV/AIDS in an Agricultural
Household:
•
Adult becomes sick
•
He/she reduces work
•
Replacement labor is “imported,” perhaps from relatives
•
Other adults work longer hours on the farm
•
Health care expenses rise
•
Household consumes less food
•
Farming switches to less labor-intensive crops and farming systems
•
Household sells off some assets (e.g. livestock) for funds
•
Nutritional status deteriorates
•
Sick adult stops work
•
Household devotes more time to sick adult, less to children and to farming
•
Debts increase
•
Children drop out of school to help with household labor
•
Adult dies
•
Funeral expenses are incurred
•
Household fragments as adults migrate for work
•
Household reduces cultivation of land, leaves land fallow
•
Household turns to natural resources for fuel, food
•
Inappropriate natural resource use leads to spread of pests and disease
•
Effects of knowledge loss intensify
•
Surviving family members lose access to land and property
•
Solidarity networks become strained, possibly to point of exclusion
•
Partner becomes sick
•
Downward spiral accelerates
Adapted from Drimie and Gandure 2005 & Gillespie and Kadiyala 2005
to be exacerbated when mean education
level is high; that is, there is a differential
loss of human capital when highly educated
community members die. The effects of
mortality on community agriculture productivity
are mitigated in wealthier communities, which
presumably have greater resources to “fall
back on” when faced with the stresses of
mortality (Jayne et al. 2006).
Despite some observed changes in land use
in conjunction with the HIV/AIDS epidemic,
the overall impacts of HIV/AIDS on agriculture
are still somewhat unclear. Because of the
diversity of agricultural practices, types of
terrain, and land use and tenure patterns in
sub-Saharan Africa, generalization about the
precise impacts of HIV/AIDS on agriculture are
not yet possible. In their review of HIV/AIDS’s
effects on agriculture and the implications for
policy, (Jayne et al. 2004:9) note that “evidence
is mixed as to how AIDS is affecting agricultural
systems and cropping patterns.”
The effects of mortality on livelihoods appear
to be dependent upon the gender and position
within the household of the deceased, as well as
upon the baseline socio-economic status of the
family (Hunter et al. 2007; Yamano and Jayne
2004). Regardless of the individual who dies, the
effects of mortality on livelihoods may be felt for
a long time. Changes in livelihoods strategies
have been observed up to three years after a
death (Barany 2003; Yamano and Jayne 2004).
HIV/AIDS-affected households may feel more
pressure to use unsustainable cultivation or
natural resources extraction techniques (Torell
et al. 2006), and social structures governing the
use of land and resources may be weakened
by AIDS-mortality. In addition, HIV/AIDSaffected individuals may feel less beholden
to these structures because of stigma and
ostracism from their communities (Ternström
Interactions between HIV/AIDS and the Environment
2005). Farmers may also be more focused on
short-term rather than long-term concerns,
as the household’s demand for “quick cash”
outweighs future considerations in the face of
what may seem imminent mortality (Torell et al.
2006). As an example, more fire may be used
for the clearing of agricultural land (Oglethorpe
and Gelman no date) because of its lower cost
and labor demand. As a result, uncontrolled
fires may enter and damage protected areas
thus further impairing the ability of these
systems to provide ecosystem services
(Gelman et al. 2005).
labor-intensive fishing activities (Gordon 2005),
thereby affecting livelihoods in much the same
way as it does for farmers.
Fisherfolk are both highly dependent
on natural resources (fisheries) for their
livelihoods, and are highly vulnerable to HIV
infection. Gordon (2005) reports on studies
that show fisherfolk being 4.4-14.0 times
more likely to be infected with HIV than the
general population in nine of ten countries
studied. Three of theses countries are in
Africa, where rates of HIV in fisherfolk ranged
from 4.5 to 5.8 times higher than in the
general population. In Kenya and Uganda the
rates were higher than those for truck drivers,
a known high-risk group, and the Kenya
study even hinted that rates were higher for
fisherfolk than for sex workers. A variety of
reasons have been suggested to explain the
high prevalence of HIV in the fisheries sector
including the age group of most fishermen
(15-35), the migratory nature of many people
involved in fishing, sudden influxes of cash
from sales, irregular working hours, and
limited access to health services.
HIV/AIDS-affected families have also been
observed to gradually sell off household
assets to gain income as a buffer against lost
labor and lost productive value. Families that
own livestock sell the animals to pay for food,
treatment, or household expenses, which
leads not only to a reduction in income, but
also to a decrease in available manure and
animal labor, which in turn further reduces
food production (Hammarskojöld 2003).
Erosion of household assets leaves families
more vulnerable to further economic or health
shocks (Barany et al. 2005). A “downward
spiral” of livelihood degradation can thereby
begin (Parker et al. 2009).
Inheritance and land tenure patterns are
also being affected by the epidemic. Land
fragmentation, lack of title deeds, and unclear
land policies regarding what happens to land
when the landholder dies are increasingly
affecting families that have experienced AIDS
mortality. Land grabbing from orphans and
widows and the practice of widow inheritance
further contribute to the vulnerability of HIV/
AIDS-survivors (Kiai et al. 2002). Women’s
rights to land, though often officially codified in
law, are often not in fact protected in practice
(Drimie 2003).
In contrast, HIV/AIDS has occasionally been
intentionally invoked to maintain or regain
control of land (Frank and Unruh 2008), as
governments sometimes have specific policies
designed to protect the rights of the HIV/
AIDS-affected.
Fisheries Sector Practices
HIV/AIDS affects production sectors other than
agriculture. Illness may undermine fisherfolks’
ability to travel long distances and perform
9
Interactions between HIV/AIDS and the Environment
Orphans and Vulnerable Children
In coastal areas experiencing decreasing fish
abundance in artisanal fishing communities
without access to boats safe for deep water or
engines, low income from fishing can lead to
food insecurity and risk behaviors that increase
vulnerability to HIV (Torell et al. 2006). For
instance, women have been reported to barter
sex for fish (Gordon 2005; Torell et al. 2006).
The intergenerational effects of the HIV/AIDS
epidemic on the environment are striking, and
are not limited to vertical (mother-to-child)
transmission of the virus. Over 11.6 million
children in sub-Saharan Africa have been
orphaned by HIV/AIDS since the beginning
of the pandemic (UNAIDS 2008 accessed
2010). Orphans and vulnerable children
(OVCs) are less likely to have been the
beneficiaries of knowledge transfer regarding
livelihoods (Oglethorpe and Gelman 2008) and
traditional social and ecological knowledge.
Gaps in traditional knowledge of farming
techniques, natural resources management,
and identification, collection, and use of
natural resources, including traditional
medicines, have been observed (Oglethorpe
and Gelman 2008; Oglethorpe and Gelman no
date; Topouzis et al. 2001). Orphans, like HIV/
AIDS-widows, are also often prone to landgrabbing by relatives or community members,
and are extremely vulnerable in terms of
livelihoods (Drimie 2002; Kiai et al. 2002).
Intergenerational “transmission” of poverty
is also common, with orphans and children
affected by HIV/AIDS less likely to be able to
climb out of poverty (Drimie 2002).
Gender Issues
Gender inequality is often mentioned, both
as a precondition for many of the deleterious
links between HIV/AIDS and the environment,
and also as an exacerbating factor. Women
are more susceptible to HIV infection, both
for biological reasons (the larger and thinner
mucous membrane of the vagina allows for
easier transmission), and for socio-cultural
reasons, such as unequal sexual power
relationships, sexual violence against women,
and the perception that women should be naïve
and passive in sexual relationships (Gupta et
al. 2003). Furthermore, women tend to carry
the majority of labor burden in household
activities, childcare, and caring for the ill (Torell
et al. 2006). In sub-Saharan Africa, women
account for 70% of the agricultural workforce
(Barany, 2003). Some food and water collecting
activities—for which women bear the brunt
of labor—are dangerous, and can themselves
negatively affect women’s health (Hyder et al.
2005). Women often have differential access to
education, employment, credit, and information
(Torell et al. 2006), and women, particularly
widows, may have difficulties in accessing
land, which is usually in their husbands’ name
(Kiai et al. 2002). Paychecks, land deeds,
and income are often directed to men, who
are generally more likely to spend household
income on alcohol, commercial sex, and
gambling, whereas women are more likely to
channel income into school fees, medicines,
and food (Kristof and Wudunn 2009). In parts
of sub-Saharan Africa, the practice of widowinheritance leaves widows penniless and
vulnerable and can also increase the spread
of HIV if either the widow or her inheritor is
infected (Kiai et al. 2002). Women are also often
subjected to coercive sex (Erulkar 2004) and
food-insecure women have been documented
to be more likely to engage in unprotected sex
and to report low power in relationships (Weiser
et al. 2007). Women are also generally more
economically vulnerable, and are more likely
in sub-Saharan Africa than men to depend on
NGOs or other aid for survival (Kanyamurwa
and Ampek 2007).
10
Interactions between HIV/AIDS and the Environment
Migration
date). Likewise, loss of normal social controls
over sexuality and natural resource use leads
to increased HIV transmission and increased
environmental degradation, respectively (UNEP
UNAIDS 2008). Wars and conflicts impose a
heavy burden. Sexual violence, crimes against
persons and property, and general social
disruption affect both people’s health and the
environment (Voeten et al. 2009).
Migration has also been identified as a link
between HIV/AIDS and the environment, and has
bi-directional effects. Rural-to-urban migrants,
seeking livelihoods in cities or fleeing untenable
rural conditions (including lack of access to land
and overly degraded land) are at increased risk
of HIV infection because of enlarged sexual
networks, increased substance abuse, higher
population viral prevalence, social disruption and
more casual and commercial sex (Mauambeta
2003; Ngigi 2006; Voeten et al. 2009). Meanwhile,
seasonal or work-related migration similarly
increases risk, primarily through partner
concurrency, lack of availability of condoms
and HIV/AIDS-education in remote areas, and
increased commercial sex (Ball 2006; Gelman et
al. 2005; Oglethorpe and Gelman no date; Torell
et al. 2006). At the same time, urban-to-rural
migration of the HIV-infected puts demands on
relatives, in terms of labor and care, and on the
natural environment, in terms of natural resources
and ecosystems services (Andrew et al. 2003;
Ngigi 2006). Migration of HIV-infected persons
from cities also spreads the virus to lowerprevalence areas like the countryside.
Climate Change
Climate change appears to be contributing
to environmental variability, via higher risk of
extreme events (Costello et al. 2009; Myers
and Patz 2009), which may lead to increased
poverty, migration, and economic vulnerability
(all risk factors for HIV transmission).
Environmental changes also foster conditions
that are favorable for disease transmission.
Degraded environments produce fewer
crops, contributing to malnutrition and all of
its negative effects on health and immunity
(Battisti and Naylor 2009; Bloem et al. 2010).
Increased distances to reach water and
decreased water quality threaten an increase
in water-borne illness, an important class of
opportunistic infection affecting PLWHA (Baker
2009). Meanwhile, each 2-3°C increase in
temperature is expected to increase malaria
transmission by 3 – 5%, which translates
to several hundred million additional cases
(McMichael et al. 2003). Because HIV and
malaria have a synergistic relationship, with
each malarial episode potentially increasing
viral load of HIV by a one-log factor for up
to eight weeks (Abu-Raddad et al. 2006).
More malaria also means more HIV/AIDS
through increased HIV infectiousness among
co-infected HIV positive individuals, and/or
increased exposure to HIV among HIV negative
individuals who receive blood transfusions.
Decreased plant diversity and species loss
may limit access to valuable plants, including
some identified as having medicinal or anti-HIV
properties (Ezeaku and Davidson 2008). The
health effects of climate change are neither
negligible nor an uncertain future outcome:
Costello et al. (2009) assert that nearly 1.9
million disability-adjusted life years were lost
in Africa in the year 2000 alone because of
climate-related factors.
Two special cases of migration link the HIV/
AIDS pandemic and the natural environment.
First, “climate refugees” (or “environmental
refugees”) are those who migrate because of
degraded environments, natural disasters, and
climate change (Bremner 2009, accessed 2010;
Development Alternatives Inc. 2001). Second,
“conservation refugees” are those who are
forced out of their homes within protected or
conservation areas and are obliged to migrate
elsewhere (Dowie accessed 2010). Dowie
estimates that up to 10 million people have
been evicted from their homelands historically
because of environmental/conservation
activities. These “conservation” and “climate”
refugees often migrate to urban areas, facing the
same risks as other rural-to-urban migrants.
Crisis Situations
Emergencies, natural disasters, conflict, and
generalized social disruption also endanger both
the environment and those at risk or infected
with HIV. A loss of community “champions” to
HIV infection has been noted to decrease social
cohesion generally, and perhaps to contribute
to communities’ decreased commitment to
conservation efforts and natural resource
management (Oglethorpe and Gelman no
Climate change will likely also produce
changes in agriculture and land use across
Africa. One prediction is that the majority of
African countries will have 50% or greater
11
Interactions between HIV/AIDS and the Environment
novel climate regimes—temperature and/or
moisture patterns beyond current extremes—
by the year 2050 (Burke et al. 2009). This will
additionally affect land use practice already
disturbed by the HIV/AIDS epidemic.
UNAIDS and UNEP produced a joint working
paper on HIV/AIDS and climate change in 2008,
in which they hypothesize an “HIV/AIDS-Climate
Change Complex” (UNEP UNAIDS 2008). They
identify food security, patterns of infectious
disease, effects of pollution and heat stress on
immunity, and issues of governance, policy,
and conflict as the major points of interaction
between climate change and the epidemic.
Impacts of Environmental Interventions on
the HIV/AIDS Epidemic
Environmental or economic development
activities themselves can in fact exacerbate
existing health problems, including increasing
people’s vulnerability to HIV and/or worsening
HIV/AIDS outcomes.
For instance, remote
conservation work
that draws men away
from their families for
weeks or months at
a time can result in
lack of entertainment,
boredom, loneliness
and excessive use of
alcohol, which can
lead to risky sexual
behavior. In areas with
low levels of supervision
or discipline, guards
may accept sex in lieu
of fines (Ball 2006;
Gelman et al. 2005;
Oglethorpe and Gelman
no date; Torell et al.
2006). Condoms and HIV/AIDS information and
education may be unavailable in the remote
areas where conservation and development
workers are posted (Gelman et al. 2005; Lopez
et al. 2005).
Interventions that give large cash incomes to
men may lead to increased alcohol use and
commercial sex (Oglethorpe and Gelman 2006).
Likewise, facilitating tourism can sometimes
facilitate HIV transmission (Torell et al. 2006).
Road building creates more mobility and more
possible routes for transmission (Stillwaggon
2006). Creating dams for hydroelectricity
fosters schistosomaisis, which is linked to
increased HIV transmission (Stillwaggon,
2006). Some environmental and development
interventions, while not contributing directly
to the HIV/AIDS epidemic, do exclude HIVaffected households by default. Rotating
credit and savings associations might exclude
orphans and vulnerable children under the age
Types of Interventions for Addressing HIV/AIDS-Environment Linkages:
•
Facilitating policy and systems-level change
•
Strengthening community institutions
•
Promoting interventions in sustainable natural resources management
•
Encouraging sustainable, environmentally friendly livelihoods
•
Engaging in HIV/AIDS-specific programming at the community level
•
Internal mainstreaming: workforce interventions at institutional level
Interactions between HIV/AIDS and the Environment
of 18 because of a minimum age requirement
(SCC 2008). Cooperatives might inadvertently
exclude HIV-positive women, as their peers
may be less likely to sign as collateral because
of fears of illness or death. Labor-intensive
improved farming techniques might not be
practicable for families who have lost labor
capacity to HIV/AIDS (SCC 2008).
Workforce and Human Capacity Impacts
of HIV/AIDS
At the institutional level (NGOs, government
agencies, and other organizations), there are a
number of other important links between HIV/
AIDS and environment. Perhaps the most salient
is the issue of workforce. Staff of environmental
and conservation organizations are not immune
to HIV; since the beginning of the epidemic,
organizations have seen an increase in
absenteeism because of illness, the demands
of caring for the ill, and frequent attendance at
funerals (Cash and McCool 2007; Mauambeta
2003). Some organizations report an increase
in demand for employee assistance programs
and medical or other support provided by the
employer (Mauambeta 2003). There are many
reports of an increase in mortality in workforces
(Ball 2006; Dwasi 2002; Mauambeta 2003; Meier
no date; Ngoti and Baldus 2004; Zelothe 2008)
and the corresponding decline in morale and
capacity to perform job activities (Development
Alternatives Inc. 2001; Oglethorpe and Gelman
no date). Nonetheless, the precise extent of
mortality and it effects on organizations in terms
of productivity and economics have not been
rigorously documented. Gelman et al. (2005)
note that many conservation organizations
are not open about staff losses related to HIV/
AIDS because of issues related to stigma and
confidentiality. Those organizations that have
reported openly show significant losses: 14% of
staff in the Wildlife and Environmental Society of
Malawi and over 80% of extension workers in a
fire awareness program in southern Africa. The
loss of skilled professionals—many of whom
are “investments” in terms of the education and
on-the-job training they have received—has
negative financial and programmatic impacts
upon the functioning of the organization.
In the environmental sector specifically, loss
of workforce has led to decreased patrolling
of protected areas and national parks (UNDP
2007), which may contribute to higher levels
of poaching and unregulated natural resource
harvesting in or near parks.
Some institutions have also reported shifts in
funding priorities from donor organizations,
either towards HIV/AIDS-focused activities and
away from environment, or conversely, away
from HIV/AIDS-related programming towards
environment (especially climate change)
activities (Koro 2004, accessed 2009; Ngoti and
Baldus 2004; Oglethorpe and Gelman no date).
Interactions between HIV/AIDS and the Environment
Historical Perspective:
IUCN-ESARO and IPPF-ARO Work on Environment—HIV/AIDS Linkages
natural resources in a sustainable manner.
This is coupled with loss of traditional
knowledge on sustainable agricultural
practices.
The links between HIV/AIDS and the
environment gained international awareness
in 2003 when the Vth World Parks Congress
in Durban, South Africa identified it as an
emerging issue. This was followed in 2004 by
a resolution passed at the IIIrd IUCN World
Conservation Congress in Bangkok, which asks
the conservation community and collaborators
to take actions that promote HIV/AIDS policies
and procedures.
• Reduced access to livelihood assets
(e.g. employment, access to credit,
etc.) may result in increased reliance on
environmental assets.
• There is also a change in land use,
whereby agricultural land is left fallow or
farming of less intensive (and usually less
nutritious crops) increases.
To better understand the links between HIV/
AIDS and the environment, the International
Development Research Centre (IRDC) funded a
series of desk reviews under a program called
“Making the Linkages – Conservation as a Core
Asset for Livelihood Security in Eastern Africa.”
IUCN-ESARO and IPPF-ARO developed a
memorandum of understanding to collaborate
on desk reviews and workshops in East Africa.
Desk reviews were conducted in Uganda,
Kenya, Tanzania, and Ethiopia (Matiru and Osur
2008; Mwakitwange and Bashemererwa 2008;
Tassew 2008; Tumwine 2007). Community
workshops were also held with funding from
IRDC, Ford Foundation and IPPF in 2007-2008
(IUCN-IDRC 2007; IUCN-IDRC 2008; IUCNIPPF-IRDC 2008). These activities led to policy
briefs and lessons learnt summaries (IUCNIPPF-IRDC 2008; Kisilibo et al. 2008; Mvoyi et
al. 2008; Nakangu et al. 2008) and a draft final
report of the entire enterprise (IUCN-IPPF 2009).
• As a result of weakened state of HIV/AIDS
patients and unclear land tenure policy,
the women and children may lose their
inheritance through land grabbing or loss
of inheritance if the male owner dies.
• Increased encroachment on protected
natural resources in search of herbal
medicine and other resources results
in conflict between communities and
animals as well as with park wardens.
• Waste disposal of condoms, syringes and
medicines that may be blood or bodily
fluid contaminated is an issue.
Environment
• Environmental degradation such as soil
erosion and loss of vegetation cover leads
to reduced crop production and hence
reduced macro- and micronutrient intake.
• Resource degradation also results
in longer distances to fetch water,
fuelwood, construction materials, and
to reach grazing sites. This in turn leads
to higher demands for labor, increased
time to acquire resources, and increased
demands for unavailable calories and
nutrients, thus stressing individuals.
Findings of the desk reviews and workshops
are summarized (IUCN-IPPF 2009) as follows:
HIV/AIDS
HIV/AIDS:
Environment:
• HIV/AIDS victims are forced by poverty to
rely heavily on natural resources to earn
income through the sale and consumption
of charcoal, timber, fuelwood, and wild
fruits and for nutritional supplements and
traditional medicines.
• Increased travel distances to resources
increases the vulnerability of women to
sexual violence.
• There is a greater incentive to exploit
resources for short-term benefits either
consciously or unconsciously using
unsustainable practices because people
affected by HIV/AIDS expect to die sooner
rather than later.
• Deterioration of fresh water resources
(wetland, rivers etc.) affects the availability
of potable water.
• Environmental degradation can result in
favorable conditions for disease outbreak
(e.g. warmer climate in the highland –
malaria).
• Premature deaths result in lack of
knowledge transfer on how to use the
14
Integrated Interventions: What
do they look like?
• The environment provides traditional
medicines, which are easy to access and
widely accepted.
• Conservation or other work in remote
places away from family increases the risk
of HIV/AIDS infection.
A growing number of organizations and
institutions are addressing HIV/AIDS and
the environment, population, health and
environment, or climate change and health in
an integrated fashion. “Mainstreaming” of HIV/
AIDS into other sector activities has become a
fashionable—even expected—response to the
epidemic. Many ministries, aid organizations,
and NGOs have added interagency
collaboration and mainstreaming of HIV/AIDS
into their boilerplate. Fewer have made onthe-ground day-to-day actionable changes in
activities and policies. Whether this is because
of inadequate funding, territorial fears, unclear
policy guidelines or other reasons is unclear.
• Eviction from forest reserves, national
parks, etc. may lead to social instability
and migration.
• Pollution and waste disposal especially
affects people living with HIV/AIDS
(PLWHA), who have special needs
with respect to water, sanitation, and
hygiene services.
• Healthy ecosystems provide for clean
air, clean water, and moderate local
climate, which may have an effect
on HIV/AIDS and other infectious
diseases.
Nonetheless, some important strides have
been made in incorporating integrated,
comprehensive responses to HIV/AIDS and
environmental issues into government and
• Climate change will significantly affect the
vagaries of nature and climatic variability
influences crop production.
15
Interactions between HIV/AIDS and the Environment
non-governmental programming. Though
integrated population, health and environment
community-based projects have existed since
the 1970s (Finn 2007), recent years have seen
an upswing in projects relating both to PHE
and those related to integrating HIV/AIDS and
environmental concerns.
•
Definitions
For the purposes of this report, we are defining
mainstreaming, multisectoral approach, and
integrated intervention as follows:
•
•
Mainstreaming refers to the process
of including HIV/AIDS considerations
into existing programming and policy of
organizations and sectors with focuses
other than health/HIV. For instance, the
Ministry of Education mainstreams HIV/
AIDS (in part) by including awareness
campaigns, HIV testing, and HIV/AIDSspecific policies into its teacher training.
Mainstreaming HIV/AIDS into a project
means that at every step of the project
cycle, from budgeting to project planning
to monitoring and evaluation, HIV/
AIDS-related concerns are anticipated
and incorporated into the process.
Organizations are cognizant that their
interventions may be affected by the HIV/
AIDS epidemic, and that their interventions
themselves may have an impact on HIV/
AIDS. Mainstreaming can include—but is in
no way limited to—internal institutional level
policy-making and awareness programs
directed at the institution’s own workforce.
An integrated intervention is one that
simultaneously—and by definition—
addresses both health/HIV-concerns
and concerns that are traditionally the
“territory” of another sector (in this case,
usually agriculture, environment, rural
development, or conservation). That is, a
project that promotes kitchen gardens to
people living with or at risk of HIV can be
seen as integrated in that it serves as both
a response to malnutrition (which affects
HIV/AIDS outcomes), and as a response to
natural resource overuse (limiting people’s
dependence on the natural environment).
In the grand scheme, even something
as broad as poverty alleviation could be
conceived of as an integrated intervention,
as it simultaneously addresses risk factors
for both HIV/AIDS and environmental
degradation. However, for the purposes of
this report, we generally define intervention
at a smaller level: NGO or governmental
programming and projects.
It is clear that mainstreaming, multisectoral
approaches to HIV/AIDS, and integrated
interventions are all important working
principles for a successful response to the links
we have identified between HIV/AIDS and the
environment (De Souza et al. 2008; FAO 2005;
Gillespie and Kadiyala 2005; e.g.,Hemrich and
Topouzis 2000; Mullins 2002; Mwaura 2007;
SCC 2008; Topouzis and du Guerny 1999;
Topouzis et al. 2001; Villareal and Holding
Anyonge 2004). Furthermore building strategic
partnerships across disciplines and sectors is
a critical component of any type of integrated
intervention (Topouzis et al. 2001).
By multisectoral approach, we mean a
coordinated response to a problem that
spans disciplinary and governmental
divisions. A multisectoral approach to
community economic development, for
instance, would mean that Ministries of
Health, Education, Finance, Women’s
Affairs, Rural Development, Environment,
and Agriculture simultaneously address the
barriers to development. Inclusion of civil
society and private sector organizations
further strengthens the response. A
multisectoral response should ideally be
more than several institutions or disciplines
acting in parallel. A sound multisectoral
approach must include collaboration,
resource and data sharing, harmonization
of monitoring and evaluation procedures,
and umbrella policies.
We maintain that as both HIV/AIDS and
environmental concerns have multiple
determinants, both proximate and ultimate,
a multi-faceted approach to mitigating their
impacts is warranted (Gillespie and Kadiyala
2005; Hemrich and Topouzis 2000; Stillwaggon
2006; Topouzis and du Guerny 1999). However,
it is critical that any of these types of initiatives
has “teeth.” Hollow promises about crossdisciplinary work or a paragraph or two of HIV/
AIDS-specific material added to a proposal
do pitifully little to advance the cause of either
environmental protection or HIV prevention.
•
16
“Mainstreaming AIDS is interpreted to
mean that AIDS-specific programs take
a bite out of every other budget, such as
having the transport ministry paint AIDS
Interactions between HIV/AIDS and the Environment
ribbons on rail cars or having agricultural
extension agents lecture farmers about
sexual behavior. It is far more effective to
find ways for each sector—whether it be
trucking, commerce, agriculture, health
care, government, or mining—to combat
the conditions that produced the epidemic,
whether they be biological, social,
behavioral, economic, or environmental”
(Stillwaggon 2006: 13).
general categories. It is important to note
that most organizations’ approaches are,
in fact, multifaceted and include several of
these types of intervention. For instance,
the International Fund for Agricultural
Development, in its Strategy Paper on HIV/
AIDS, identifies numerous priority areas for
intervention, including overall incorporation
of HIV/AIDS concerns into project planning—
external mainstreaming—poverty alleviation,
introduction of innovations in food security and
nutrition, implementing socio-economic safety
nets, and integrated workplace interventions—
internal mainstreaming (Topouzis et al. 2001).
Key Principles: Gender and
Participation
Several key principles must guide interventions
on the links between HIV/AIDS and the
environment, no matter which sector(s) or
at which level(s) they are implemented. The
first is awareness of gender inequality as
a concern for programming. Advocacy for
gender equality at the household, community,
institutional, national, and international levels
is a vital component of every intervention
addressing this nexus (e.g., Gupta et al. 2003;
SCC 2008; Torell et al. 2007; Torell et al. 2006).
Internal policies that reflect equality as a
working principle (such as non-discriminatory
hiring practices) should also be pursued.
Gender equality is, in fact, one of the working
principles of the Millennium Villages Project in
achievement of the Millennium Development
Goals (Kates 2007).
Nonetheless, for discussion, it is helpful to
separate various types of intervention. We
have arbitrarily (and loosely) organized these
intervention types from the macro- to the
micro- level. This in no way reflects the relative
importance of each type of intervention.
The second key principle is inclusive and
broad-based participation. Stakeholders,
including people living with HIV, children,
women, and marginalized populations,
should be considered throughout the project
lifecycle (Ezeaku and Davidson 2008; Save the
Children and Oxfam International 2002). Unless
communities and stakeholders are included
and take on meaningful roles, there will be
no traction (“buy-in”) for projects, and any
intervention is likely to fail.
Facilitating policy and systems-level
change
Evidence for many of these intervention types
comes from the grey literature: industry reports
and toolkits. While well-researched and wellreasoned recommendations and theories
certainly exist in both grey literature and
published journals, actual evidence evaluating
the impacts of intervention types is quite limited.
We shall now discuss each of these types of
intervention in greater detail, providing examples
of successful interventions, as appropriate.
Neither the HIV/AIDS epidemic nor
environmental degradation can be stopped
without systemic change of the factors that
generated the problems in the first place
(Hemrich and Topouzis 2000; Stillwaggon
2006). A full spectrum approach to HIV/AIDS
prevention, treatment and support needs
to link health to poverty alleviation, gender
equality and human rights with an emphasis
on education, health, agriculture, economic
development and environmental issues
(Oglethorpe and Gelman, 2008)
Types of Interventions for
Addressing HIV/AIDS and the
Environment
Policy affects all of the activities under its
purview. National and international health,
HIV/AIDS, environmental, conservation, land,
agriculture, educational, trade, and finance
policies—to name a few—play important roles
in our ability to address both HIV/AIDS and the
environment, and the links between the two. For
Below is a discussion of various interventions
and approaches that have been attempted in
the past for simultaneously addressing HIV/
AIDS and the environment. For purposes
of clarity, we have divided the types of
interventions addressing links into six
17
Interactions between HIV/AIDS and the Environment
instance, national land policies may not yet be
equipped to deal with the large scale mortality
wrought by HIV/AIDS, leaving widows and
orphans unable to inherit property, and therefore
dependent for survival upon natural resources,
NGO support systems, or risk behaviors like
transactional sex (Kiai et al. 2002).
more easily managed (McMichael et al. 2008b;
Stillwaggon 2006). Supporting education
systems, and particularly girls’ education
will likewise foster resilience at a population
level. Successful achievement of Millennium
Development Goal 1, poverty alleviation, would
likewise bring the poorest of the poor out of the
highly vulnerable state in which they now live.
The highly sectoralized structure of most
government entities is a barrier to implementing
comprehensive interventions. Funding streams
are similarly often vertically structured, and
funding agencies may be reluctant to devote
resources to activities they perceive as
being outside of their “territory” or expertise.
Harmonization of policy and the creation of
“umbrella policies” will be necessary for true
multisectoral work (Hemrich and Topouzis
2000). To move beyond competition and turfguarding, incentives need to be identified to
encourage multisectoral work.
Systems level interventions must also work
to address issues such as climate change, by
developing plans to prevent, mitigate, and adapt
to the vagaries of climate that the earth is likely
to experience in coming years, and to “climateproof” societies insofar as possible against the
effects of extreme weather events and natural
disasters (Frumkin and McMichael 2008; Save
the Children and Oxfam International 2002).
Interventions to slow the rate of global climate
change are also important.
Migration issues are a final key issue that needs
to be addressed by policy- and systems-level
advocacy and change (Cernea and SchmidtSoltau 2006; Frank and Unruh 2008; Jayne et al.
2004). Policies and eventualities for dealing with
internally displaced people (IDPs), refugees, and
international migrants must be bolstered.
International trade and aid policies must also
be systematically evaluated to determine
their friendliness for developing economies
(Ezeaku and Davidson 2008; Lotze-Campen
and Schellnhuber 2009; Save the Children and
Oxfam International 2002).
Other structural interventions will likewise be
vital for addressing the extensive, pernicious
links between the environment and HIV/
AIDS. As poverty, lack of infrastructure, and
food insecurity inextricably link HIV/AIDS and
the environment, interventions addressing
poverty alleviation, sustainable food systems,
infrastructure improvement, and economic
development (e.g., Kates 2007 ) are vital for
addressing the vicious cycles of increasing HIV/
AIDS and increasing environmental destruction.
Policy advocacy and systems strengthening
have gained momentum in the literature as
potential solutions to health and environmental
woes (e.g. (Hemrich and Topouzis 2000), and
are surely underway in a number of contexts.
Documentation, monitoring and evaluation of
this type of intervention, however, are lacking.
One key example of systems-level intervention
in the HIV/AIDS-environment network is the
Millennium Village Project. The Millennium
Villages Project is a UN-sponsored initiative
that aims to empower impoverished
communities in rural Africa to achieve the
Millennium Development Goals within 10
years. There are 78 millennium villages in
sites in Kenya, Ethiopia, Ghana, Malawi,
Mali, Nigeria, Senegal, Rwanda, Tanzania,
and Uganda. The villages work with a variety
of experts including scientists from Earth
Institute at Columbia University and other
institutions, as well as local development
experts in agriculture, nutrition, health,
education, energy, water, communications,
and the environment (Mwaura 2007). In
Sauri, Kenya, for instance, the Millennium
Villages project (Kates 2007) is addressing the
following major cross-sectoral issues (Table 3).
Critical interventions of this type must include
water and sanitation programs, projects
to increase food production or equitable
distribution of food, and health systemsstrengthening including access to primary care,
maternal-child health programs, prevention of
infectious diseases, and general health and
hygiene promotion.
Small- or large-scale economic development
projects bolster economies and foster resilience
(FAO 2005; Topouzis et al. 2001; Villareal and
Holding Anyonge 2004). When households
are universally less vulnerable, the impact of
any shock—be it disease such as HIV/AIDS,
climate change, natural disasters, or conflict—is
18
Interactions between HIV/AIDS and the Environment
building and increasing awareness for meeting
the MDGs at all levels. They call for awareness
raising, education, reporting, data gathering
and inventories, public participation and
research and training. This kind of capacity
building and systems’ improvement will be
critical for addressing the structural factors
that link HIV/AIDS and the environment. There
is also no clear pathway to sustainability: that
is, once the donor money is gone, who will
provide/buy fertilizer, seeds, bednets, pay
health clinic workers, etc.
Table 3: Cross-sectoral issues addressed by the
Millennium Village Project in Sauri, Kenya
(Adapted from Mwaura, 2007)
Population
security
Agriculture and food
IssuesWater supply
Transport and communication
Education
Capacity building
Housing, hygiene and energy
Health
Issues
Health center
HIV/AIDS
Environment
Issues
Watershed protection
Riparian zone protection
Tree planting
Strengthening community institutions
Because deteriorating community institutions
have been cited as contributing to the
pernicious interactions between HIV/AIDS and
environmental degradation (Andrew et al. 2003;
Dwasi 2002; Oglethorpe and Gelman no date),
interventions at this level are important. Capacity
building for local institutions is an important step
in addressing the HIV/AIDS and environmental
issues that communities are facing.
Kates (2007) reports that Millennium Village
Projects in Kenya, Ethiopia, and Malawi have
reduced malaria prevalence by distributing bed
nets and generated crop surpluses, enabled
school feeding programs and provided cash
earnings for farm families by distributing
fertilizers and improved seed varieties which
increased crop yields. Crop yields increased
between 85% and 350% (Buse et al. 2008). In
Koraro, Ethiopia, the clinic saw a 50% drop in
suspected malaria cases between 2005 and
2006 (Buse et al. 2008). It is still too early to
say if the Millennium Village Project approach
will be successful. That fertilizer increases
crop yields and that mosquito nets decrease
the incidence of malaria was already known
and do not provide strong evidence of the
value of holist, system-level interventions.
Rich (2007), following a visit to Sauri, Kenya,
reports that there are the same underlying
problems in Sauri as elsewhere, such as
competing government entities, favoritism
and gender inequities. He also spoke with
critics of the project, most of whom feared
reprisals for speaking out and only spoke
on the condition of anonymity. Carr (2008)
presents a detailed theoretical critique of the
Millennium Village Project framework and notes
that there are many problems with recognizing
and addressing the diversity of people and
problems at the village scale which are not
being rectified.
Community-based natural resource
management (CBNRM) has increasingly been
used as a participatory approach to natural
resources protection and management. One
group of researchers (Nkonya et al. 2008)
studying CBNRM in Uganda noted several
factors that affect the strength and capacity
of communities to enact natural resource
management. They found that the presence
of government or NGO agriculture and
environment projects in a community tends to
encourage implementation of CBNRM, while
insecure land tenure affects CBNRM negatively.
They suggest that improving human capital,
conditions of natural resources, and market
access for communities will in turn strengthen
their capacity to perform effective CBNRM.
Namibia’s Association of Community Based
Natural Resource Management Support
Organizations (NACSO) is a good example
of how strengthening community institutions
can help to address both natural resource
management and HIV/AIDS. NACSO not only
reaches remote communities with support
from their CBNRM programs, but also
undertakes HIV/AIDS education and awareness
interventions in these communities. NACSO has
also successfully implemented monitoring and
evaluation systems for CBNRM organizations
(DeMotts 2008; Oglethorpe and Gelman 2008;
Oglethorpe and Gelman no date).
A lingering concern for the Millennium
Development Goals and the Millennium Village
project is that of capacity building. Pisupati
and Warner (2003) note the need for capacity
19
Interactions between HIV/AIDS and the Environment
Other community-based institutions are
similarly well placed to have an impact on the
environment-HIV/AIDS linkages. For instance,
Topouzis and du Guerny (1999) call for
changes in the agricultural extension model,
which has traditionally been about commodity
crops and conducted by and targeted to men.
This system could be strengthened to better
address issues of AIDS-widows struggling with
food insecurity and to provide more information
on locally produced and consumed crops.
Other institutions, such as social, religious,
economic, justice, and local governmental
organizations also need bolstering to address
the environment-HIV/AIDS linkages we have
mentioned at the community level (FAO 2005).
resources. Some organizations have managed
this issue by allowing controlled harvests of
natural resources near—but not in—protected
areas (Shackleton et al. 2007).
Reviving traditional knowledge systems
regarding natural resource collection and use
has also been used as a technique to minimize
the environmental harm done by increased
pressure on the natural environment for
survival (Du Guerny and Hsu 2004; Garí 2004).
Traditional knowledge systems often care well
for the resource base (Du Guerny and Hsu
2004). Encouraging, educating, and supporting
orphan (De Souza et al. 2008) and female
(Oglethorpe and Gelman 2008) resource-users
within traditional systems can particularly
facilitate responsible use.
Promoting interventions in sustainable
natural resources management
Junior Farmer Field Schools have been
implemented in Zimbabwe with orphans and
vulnerable children to build the skills of HIV/
AIDS-affected children in rural areas to meet
their dietary and income needs while also using
natural resources sustainably. Of particular
interest to the project is the development of
livelihood options that allow orphans to support
themselves while “producing appropriate
behaviors that lessen the epidemic’s impact
on their generation” (De Souza et al. 2008:
222). The project uses hands-on, participatory
learning, and incorporates health education
and HIV-prevention messages as well. Though
the program has been anecdotally described
as benefiting both the children involved and the
community as a whole, there has not yet been
a formal assessment of its impacts (De Souza
et al. 2008).
Because of the connection between the HIV/
AIDS epidemic and natural resource use,
interventions that deal primarily with the use
of natural resources can also incorporate
aspects that are beneficial in addressing the
environment-HIV/AIDS nexus.
One fundamental piece in considering the HIV/
AIDS-effects of natural resource management
programs is the improved management of
protected areas (Dowie accessed 2010).
Dowie reports that more that 10 million
people have historically been displaced from
their homelands because of conservation or
environmental programs. These “conservation
migrants” face increased risk of HIV infection
and are less likely to be able to cope with any
kind of shock, be it economic, environmental,
or health-related. Minimizing conservationbased migration must be a priority in managing
protected areas (Cernea and Schmidt-Soltau
2006; Dowie accessed 2010). Cernea and
Schmidt-Soltau (2006) note that policies
that displace people from protected areas
sometimes backfire in their goal to protect
biodiversity, as intensive harvesting at the
borders of the protected areas threatens
species.
Interventions to manage sources of traditional
medicines being used to treat opportunistic
infections and to manage HIV/AIDS symptoms
are also needed (Barany et al. 2005).
Management can be based on the use of
natural woodlands or on the domestication
of species for cultivation. Barany et al.
(2005) suggest that, where possible, support
for the management of medicinal plants
in natural settings, including sustainable
harvesting methods and forming users’
associations, should be attempted before
resorting to domestication. Identification of
priority species is an important first step in
formulating management plans, and should be
accomplished in coordination with traditional
healers’ associations.
There is a fine balance between protecting
biodiversity, endangered species, and areas
of particular environmental interest (such
as national parks and protected areas), and
protecting the livelihoods and food security
of the people who depend upon natural
20
Interactions between HIV/AIDS and the Environment
Encouraging sustainable, environmentally
friendly livelihoods
One of the more common and betterdocumented intervention types is the
encouragement of livelihoods (income
generating activities, or IGAs) that at once
strengthen the economic base of vulnerable
households, and promote ecologically sound
techniques or technologies.
Natural resource-based income generation
has been a popular intervention. Activities
such as bee-keeping, animal husbandry,
cultivating medicinal plants, kitchen gardens,
encouraging use of animal manure as fertilizer,
etc., simultaneously provide livelihoods for
vulnerable families, and are beneficial (or at least
not harmful) to the environment (Bukusuba et al.
2007; Ellis and Allison 2004; Ngoti and Baldus
2004; Topouzis et al. 2001). Note that examples
of this type of intervention are often described
in the literature, but that we found few published
accounts with comprehensive analyses of the
success of this type of intervention.
The Swedish Cooperative Centre (SCC)/VI
Agroforestry encourage non-labor intensive
livelihoods such as beekeeping, animal
husbandry, and cultivating tree-seedlings to
established groups of people living with or
affected by HIV/AIDS in Kenya. The Aluor
Widow’s Group near Kisumu, Kenya, has dealt
with issues of land tenure, low labor availability
(most of its members are elderly, and many
are living with HIV/AIDS themselves), and
environmental threats such as flooding by
working together as a group to produce goat’s
and cow’s milk, local poultry, and timber- and
fruit-tree seedlings as a mechanism for earning
money and ensuring livelihoods (personal
communication, 11 March 2010).
The introduction of labor saving and
ecologically sound alternative technologies,
such as biogas production, improved cooking
stoves, bamboo coffins, and water purification
techniques has also eased the burden on HIV/
AIDS-affected households, while promoting
technologies that have environmental benefits.
A project in Thika, Kenya, supported by Family
Health Options Kenya (FHOK), has current
and former female commercial sex workers
producing and selling “jiko” improved cooking
stoves as a means of generating income. The
stoves use less fuel wood than the traditional
three-stone stove and reduce the amount of
smoke released in the cooking area. While the
construction, sale and installation of stoves
has not yet allowed most of the women to
completely stop engaging in commercial sex
(uptake has been slow because of a lack of
disposable income at the community level for
making a major purchase such as a stove), the
support group members report that they are
personally very happy with the technology, as it
saves them time and money and produces less
pollution, and they are hopeful that the project
can be scaled up as a successful small business
(personal communication, 22 Feb 2010).
Promotion of home or kitchen gardens is a
particularly convenient integrated intervention
for simultaneously addressing food insecurity,
HIV vulnerability, and environmental concerns.
Many of the foods that can be grown in
small home gardens are highly nutritious,
can provide a wide range of micronutrients,
and are particularly suitable for meeting the
nutritional needs of people living with HIV/
AIDS (Garí 2004). Medicinal plants have also
been successfully cultivated in home gardens
(Oglethorpe and Gelman no date). Gardens are
suitable for households that have lost labor,
Kitchen Gardens, Crop Diversity and the Promotion of Traditional Neglected Crops
•
Enrich diets and improve nutrition
•
Manage labor shortages through small size, closeness to home, fewer peaks in labor intensity
•
Diversify household income
•
Make better use of water, fertilizer, and pesticide inputs
•
More resistant to ecological shocks (pests, drought, etc)
•
Maintain sociocultural traditions, indigenous knowledge
•
Possibly reduce dependence on natural resources
Adapted from (Frison et al. 2006; Garí 2004; Murphy 2008)
Interactions between HIV/AIDS and the Environment
income sources, and traditional knowledge,
and can increase food and livelihood security.
They are usually close to the home, minimizing
transport and time considerations, and are
often maintained by women or orphans and
vulnerable children (Murphy 2008). In areas
with limited available land, plants can be grown
in large sacks and vines can be trained up walls
and onto roofs. A Kounkuey Design Initiative
(KDI, a Harvard University School of Design
organization) project in Kibera slum in Nairobi
is making compost from household waste for
use in sack gardens (personal communication
2/26/2010).
skeptical—even hostile—towards the group,
community members have now seen the
success of the interventions and are supportive
and have even come to the group’s plot to
learn improved farming techniques. The group
also has a Village Savings and Loan group
for microfinance of members’ own individual
income generating activities. The group has
written a strategic plan for the next three years,
and is working on publicity and documenting
successes. The Kenya Agricultural Research
Institute (KARI) has provided technical
assistance, and is helping the group to conduct
a trial of banana varieties—planted near one
another and taken care of similarly—and group
members will select their preferred variety for
their own households based on the results
(personal communication, 9 March 2010).
A related intervention is the introduction of
alternative agricultural practices, including
crop diversification and agroforestry projects.
These interventions, which often require less
labor than traditional agriculture, bolster food
security and household assets for vulnerable
families and promote sustainable land
management practices. (Frison et al. 2006)
have shown that food- and food-diversity
based interventions are more successful than
single-nutrient based ones for combating
malnutrition. This type of intervention also
protects “neglected” traditional crops, which
may have significant nutritional value, require
less intensive labor (because of extended
harvesting periods) and fewer inputs in terms
of fertilizers and pesticides, and may be
more resistant to ecological shocks such as
flood or drought (Garí 2004). Agrodiversity
and alternative agriculture interventions
simultaneously promote economic selfsufficiency, socio-cultural traditions and values,
and biodiversity (Frison et al. 2006).
It is interesting to note that the character of
the group, the local environmental situation,
and other variables, including individual
personalities and extent of illness, all have an
impact on the success of a project. We visited
a number of community groups attempting
similar livelihoods interventions, and observed
a wide range of success, enthusiasm,
ownership and sustainability of the projects.
Ecotourism has also been explored as
a possible intervention for promoting
livelihoods in an environmentally friendly,
sustainable manner. Tourism is a major
industry and source of capital for many subSaharan countries. Beautiful landscapes,
rich biodiversity, and exotic flora and fauna
act as magnets for tourists, including
many international visitors. Organizations
have capitalized on this source of income
to provide sustainable livelihoods while
simultaneously working to preserve the
environmental features that draw tourism to
Africa in the first place.
Swedish Cooperative Centre (SCC)/VI
Agroforestry’s intervention with the Oogo
Village PLWHA Group in Western Kenya is a
good example of a comprehensive agricultural
livelihoods intervention. The group, which
consists of 35 members (including 2 OVCs
and 20 widows), has implemented a number
of projects, including bee-keeping, husbandry
of a dairy cow and poultry, a tilapia pond,
intercropping, cultivation of indigenous
nutritious vegetables, tree-planting for timber
and fuelwood, and tissue cultures of various
banana varieties. The group also works on
stigma alleviation and HIV/AIDS awareness
campaigns in the community and supports
local orphans and vulnerable children with milk
and money for school uniforms. While group
members report that the community was at first
The Il Ngwesi Community Ecotourism Project
in Kenya is a salient example of an integrated
ecotourism project that simultaneously
addresses population, health/HIV/AIDS
issues, and the environment. The project has
achieved a number of impressive results in
terms of holistic community development. It
has constructed schools, provided bursaries
for school attendance, created a radio security
network backed up by armed community guards
with vehicles, generated a source of income
for a number of formerly unemployed women
through craft-making and marketing, promoted
22
Interactions between HIV/AIDS and the Environment
parallel with health sector activities, or ideally,
as part of an integrated approach.
good pasture management including reducing
problems of localized overgrazing, reintroduced
locally extinct animal populations, established
mobile clinic services, and initiated a major HIV/
AIDS awareness campaign (Mwaura 2007). The
success of the Il Ngwesi Community Ecotourism
Project depended upon linking conservation and
ecotourism to salient community concerns such
as economic vulnerability, high levels of conflict,
problems of health and access, and lack of
educational opportunities.
Environmental agencies have reported
involvement in HIV prevention, treatment,
care and support activities, such as opening a
voluntary counseling and testing (VCT) center
in a remote area, having conservation workers
provide HIV/AIDS education and condoms,
and hiring medical staff to be a part of their
workforce (DeMotts 2008; Meier no date). These
interventions occasionally include broader
health-based initiatives, such as opening a small
mobile primary care clinic, or advocating for
child immunization (Gelman et al. 2005).
Limitations to the use of ecotourism as an
intervention may include: large start-up
capital, reliance on technical knowledge and
technologies that are not always available
locally, and the risk that tourism may, in fact,
exacerbate HIV transmission by increasing the
size of sexual networks, providing large cash
incomes largely to men, and possibly promoting
commercial sex. Ecotourism interventions may
also exclude the HIV/AIDS-affected because of
tourists’ negative reaction to seeing visibly sick
workers (Lopez et al. 2005; Meier no date).
Interventions in this arena are often considered
to be part of “external mainstreaming,”
that is, organizational thinking about how
development, environmental, and conservation
activities can exacerbate conditions that foster
HIV transmission, or how to integrate HIV/
AIDS activities into conservation/environmental
work. It also includes considering HIV/AIDS
issues in strategic planning, and including
specific budget line items for HIV/AIDS-specific
programming (SCC 2008; Topouzis et al. 2001).
It is interesting to note that at least one
paper (Ziervogel and Drimie 2008) maintains
that livelihoods interventions will always be
insufficient to stem the effects of HIV/AIDS on
the environment unless national and local level
political structures adequately support the
processes and work to integrate them.
Evaluation of this kind of mainstreaming or
marginally integrated approach can be difficult.
One systematic review examining the more
common and better-documented implementation
of integrated family planning and HIV/AIDS
interventions was able to conclude only that
integration had “mostly” positive or mixed results.
Furthermore, the rigor of the studies examined
was ranked at only 3.25 of 9 possible points on a
scale that included metrics such as inclusion of
pre/post intervention evaluation, use of a control
group, control for confounders, etc. (Spaulding et
al. 2009).
For example, there is an active youth group in
the Mitumba slum in Nairobi, Kenya, working
on garbage collection for community hygiene
and aesthetics. However, because of space
and financial constraints, the waste is being
dumped in an open pit, which was recently
plowed over by the city administration in the
construction of a new bypass road. The pit is
a site of open defecation and pests, which is
immediately adjacent to the community, and
is near a source of water. Poverty, land tenure
issues, legal concerns, and inconsiderate
political decisions limit the efficacy of even
well intentioned and locally managed projects
(personal communication 2/22/2010).
Ziervogel and Drimie (2008) therefore suggest
that “holistic environmental and social
approaches” are necessary.
An example of this type of intervention would
be the Wildlife and Environmental Society of
Malawi’s (WESM) direct support of community
based organizations to provide HIV/AIDS
awareness and prevention education, VCT
services, and health services such as STD
testing and treatment and family planning.
WESM provides resources such as funding
and transportation assistance to these
organizations, and allows them to conduct
activities in geographic areas (such as near
protected areas) where these organizations do
not typically operate. WESM’s staff members
themselves are also trained to conduct
awareness campaigns in the remote areas
where they work (Mauambeta 2003).
Engaging in HIV/AIDS-specific
programming at the community level
Environmental, conservation, agricultural and
related organizations can undertake HIV/AIDSspecific programming in communities, either in
23
Interactions between HIV/AIDS and the Environment
Internal mainstreaming: workforce
interventions at institutional level
AIDS policies have been created at a number
of organizations including IUCN, World Wildlife
Fund, Ezemvelo KwaZulu Natal Wildlife, Wildlife
and Environmental Society of Malawi, and
Swedish Cooperative Centre to deal with the
inevitable issues that an HIV/AIDS-affected
workforce will face, such as time off for funeral
attendance and caring for sick family members,
non-discrimination policies aimed at protecting
sick workers, and provision of health insurance
and death benefits. A number of guidelines for
internal mainstreaming have also been created
(e.g., Cash and McCool 2007; Development
Alternatives Inc. 2001; Mauambeta 2003;
Mullins 2002; Office of the Senior Gender
Advisor 2006; Oglethorpe and Gelman 2006;
Topouzis et al. 2001; Torell et al. 2007).
Internal mainstreaming of HIV/AIDS into
conservation, environmental and development
organizations is well documented in the gray
literature (Ball 2006; Mauambeta 2003; Meier
no date; Oglethorpe and Gelman no date; Rau
2003; SCC 2008; Zelothe 2008) and it is clear
that this is an important—if not sufficient—
response to the growing evidence of the links
between HIV/AIDS and the environment. At
the very least, internal mainstreaming should
help stem the impacts of the epidemic within
organizations’ own workforce.
Examples of interventions undertaken include
HIV/AIDS awareness, education, and behavior
change campaigns, condom distribution,
provision of healthcare at the workplace
(including antiretroviral treatment), programs
to reduce stigma and discrimination within the
work environment, and employee financial and
psychosocial support programs. Internal HIV/
Internal mainstreaming techniques include
interventions to reduce staff vulnerability to HIV
infection, for instance providing workers with
safe housing or attempting to post workers
near their families. Adaptation to workforce
issues and loss of trained staff includes a move
Table 4: Internal mainstreaming activities for HIV/AIDS at two conservation organizations
Wildlife and Environmental Society of
Malawi (WESM)
Ezemvelo KwaZulu Natal Wildlife (EKZNW)
Effects of HIV/
AIDS observed in
workforce
Increased absenteeism, low
attendance at meetings, increase
in requests for short-term loans
& employee assistance. Poaching
and increased harvesting of natural
resources observed as a result of
decreased conservation workforce.
Increased absenteeism & turnover, loss
of productivity, institutional memory
impaired, natural resource use affected.
Customers react badly to seeing visibly
sick employees.
Internal HIV/
AIDS policies and
funding of HIV/
AIDS activities
No internal policy yet created,
but existing policies are largely
inclusive of PLWHA. Convinced
donors to allocate budget
specifically for HIV/AIDS (5-7% of
overall donor funding earmarked
for HIV/AIDS activities).
Internal policy deals directly with HIV/
AIDS, and has been reviewed in light
of the epidemic. HIV/AIDS committee
established. Strategic Plan includes a
line item for HIV/AIDS, with indicators,
deliverables, and measurement. Funding
specifically earmarked for HIV/AIDS.
HIV/AIDS
services offered to
employees
Including HIV/AIDS education
in new employee orientation.
Established an HIV/AIDS resource
center. “Social Welfare Committee”
for assisting bereaved staff started.
Designation of a staff HIV/AIDSfocal person. Condom distribution.
Benefits structure (including health
insurance and retirement) reorganized
to accommodate PLWHA. Three nurses
and one social worker hired to provide
in-house counseling. Linkage to ARV
treatment. Condom distribution
Other interventions Training of trainers for partner
organizations to provide HIV/AIDS
education and services.
24
Peer educators trained to offer health
education on HIV prevention, and to work
to decrease stigma and discrimination.
Interactions between HIV/AIDS and the Environment
toward additional mentoring of junior staff,
task shifting, and additional skills training to
broaden the knowledge and skills base of the
workforce (Oglethorpe and Gelman no date).
Topouzis and du Guerny (1999) present seven
strong case studies detailing some possible
unintended consequences (both positive and
negative) of development projects on the
HIV/AIDS epidemic. In planning programs,
every effort must be made to anticipate—and
manage—this kind of spillover when planning
projects in any sector.
The Wildlife and Environmental Society of
Malawi and Ezemvelo KwaZulu Natal Wildlife
have both implemented fairly comprehensive
workplace HIV/AIDS policies, as detailed in
Table 4 (Mauambeta 2003; Meier no date).
Strengths and Weaknesses of
Intervention Practice
Avoiding Unintended
Consequences:
While it is clear that there is growing interest in
mainstreaming and addressing HIV/AIDS and
the environment in an integrated, multisectoral
fashion, specific evidence regarding the
successfulness of interventions is still lacking.
Monitoring and evaluation is a critical concern
for implementing interventions, and has too
often been overlooked.
Part of responsible mainstreaming and
integration means making every reasonable
effort to anticipate unintended consequences
of an intervention. There are many anecdotes
about well-intentioned projects (in all sectors)
going awry. One involves a training project
with a group of facilitators and commercial sex
workers aimed at educating the sex workers
on safe sex. By day two of the workshop, most
of the facilitators were not only having sex with
the sex workers but also among themselves.
Sadly, many of them became HIV-positive as all
but one of the sex workers was HIV-infected at
the time (personal communication, 17 February
2010). Another anecdote involves the Volta
River Dam project, which in the 1950s and
1960s in Ghana displaced thousands of people
from their land. Men went to work in factories
and cities, while many women, destitute and
with no skills or opportunities, resorted to
commercial sex work. A 1995 survey found
that in seven of the eight sentinel surveillance
sites, HIV prevalence ranged between 1%
and 4%. The eighth site, where the dam had
affected land tenure, had HIV infection rates
five to ten times above the level of average HIV
prevalence in Ghana (Topouzis and du Guerny
1999). While causation is impossible to tease
out of a complex situation like this one, it is
clear that the infrastructure project may have
had long-term unintended consequences in
terms of HIV transmission.
We have observed that most of the
interventions addressing HIV/AIDS and
the environment are relatively small scale
(the Millennium Village Project being the
major exception), and are usually, and often
appropriately, very specific to the geographic,
cultural, and epidemiological profile of the
project site. While this is probably useful
programmatically in terms of successfully
addressing the specific needs of the target
community, it means that comparing
interventions is extraordinarily difficult.
The language of mainstreaming is often vague;
it is critical to define, insofar as possible, what
precisely we mean when we talk of “capacity
building,” “added value,” or “integration.”
The use of appropriate indicators is one
crucial step toward being able to understand
a program’s true impact and to compare it to
other similar interventions.
Disentangling the results of a single project—
especially a multisectoral one—from background
longitudinal changes, and confounding factors
is a tricky endeavor. Improving methodologies
for having a “control” or comparison group,
for adjusting for confounders, for collecting
longitudinal data (including good baseline
information), and for detecting other changes that
may be affecting the results of an intervention
should be priorities. We did not find examples of
existing community randomization or step-wedge
trials for evaluating interventions, but these may
be options for future studies.
Projects that increase cash income, especially
to male heads of household can lead to
disposable income that may be diverted to
commercial sex. Livelihoods interventions
may inadvertently exclude HIV/AIDS-affected
households because they lack the physical
capacity to engage in labor-intensive activities
(SCC 2008; Thangata et al. 2007).
25
Interactions between HIV/AIDS and the Environment
Knowledge Gaps
There is a distinct feeling that organizations
and individuals working on integrated
HIV/AIDS-environment interventions are
working in isolation. The small-scale and
highly locally contextualized nature of
many of the interventions is one barrier to
scale-up and comparability. Information
and experience sharing—developing a set
of best practices and a framework from
which to launch integrated projects—will
be tremendously helpful in solidifying the
good work that is already being done.
The FRAME online network (http://www.
frameweb.org), sponsored by the African
Biodiversity Conservation Group (ABCG)
and others is an example of a tool designed
to let implementers share their stories,
successes, and challenges in a public forum.
Nonetheless, a barrier to implementing this
kind of network is access; people working in
environmental and conservation in Africa are
often far from the kind of infrastructure, like
affordable broadband Internet, which allows
this type of communication to be truly fruitful.
There has been a clear surge in the past
decade in enthusiasm, activity, and momentum
for work—both research and implementation
focused—on the links between HIV/AIDS
and the environment. We had not anticipated
finding as many materials on the subject
as we did. Nonetheless, the vast majority
of the evidence remains anecdotal and/
or unreplicated. The anecdotal nature of
much of the evidence does not imply that
the conclusions reached are in error, but
rather that data to back up many of the
conclusions should be validated to provide a
strong, evidence-based platform for program
development and to maximize the return on
investment in these new programs.
We read over 200 documents, of which 177
were included in the writing of this report.
Many excellent reports from various agencies
contain valuable information on the links
between HIV/AIDS and the environment. There
are also good guidelines and toolkits available
from various agencies for how to mitigate the
effects of HIV/AIDS, e.g., via mainstreaming.
However, there are relatively few peerreviewed cited research documents in these
reports and many reports cite other reports.
For example, of more than 140 citations in
4 IUCN-ESARO/IPPF-ARO desk reviews
(Matiru and Osur 2008; Mwakitwange and
Bashemererwa 2008; Tassew 2008; Tumwine
2007) on HIV/AIDS and the environment in
East Africa, only 12 could be clearly identified
as being in peer-reviewed journals, and 6
of those were medically related. Our review
located 48 peer-reviewed original research
articles. This implies a failure to get original
research into the hands of policy makers for
There is always concern with highly funded
subject areas such as HIV/AIDS, that funding
dictates practice, that vertical programs
create parallel systems, and that equally
important community issues go unaddressed
when HIV/AIDS takes the stage. Whenever
possible, implementers should try to bolster
existing community structures, to focus on the
important (rather than strictly the fundable)
questions, and to use participatory methods
to conduct on-the-ground needs assessments
in communities. HIV/AIDS is a development
issue, as is environmental sustainability, and
the two must be addressed in a context of
sensitive, culturally competent, appropriate
development work.
The excitement and momentum of multiple
funders, NGOs, and other agencies wanting
to get involved in mainstreaming and in
integrated PHE or HIV/AIDS-environment
programming rings with optimism of what
can be achieved in this field. While there is
promising growth in terms of both research
and implementation, the field is still “new,”
and the subject is ripe for investigation
and action. Ensuring both a strong base of
evidence and sensibly monitored and wellevaluated interventions, however, will be
critical for the success of the field.
Important Research Needs in
Investigating HIV/AIDS-Environment
Linkages:
• HIV/AIDS, natural resource use, and
livelihoods related research needs
• Climate change related research needs
• Health and HIV transmission related
research needs
• Issues of scale
26
Interactions between HIV/AIDS and the Environment
is documentation of status and trends of the
various resources and of the extent of use
by HIV/AIDS affected households vs. poor
households without HIV/AIDS. Similar issues
exist in the broader environmental arenas of the
agricultural, livestock and fisheries sectors.
Research Priorities for HIV/AIDS,
natural resource use, and livelihoods
related research:
•
Traditional medicines, and natural
resource use
•
Socioeconomic effects, livelihoods and
coping strategies
Below, we discuss in more detail specific gaps
identified in the literature.
•
Management, governance and markets
•
Migration and land tenure
The literature we reviewed is rife with calls for
research to address a wide range of knowledge
gaps. One of the overall themes in many
of the documents is for better integrated,
multisectoral research and approaches (Anema
et al. 2009; Barany 2003; Costello et al. 2009;
De Souza 2009; De Souza et al. 2008; Dwasi
2002; Hemrich and Topouzis 2000; Hunter et al.
2008a; Oglethorpe and Gelman 2008; Parker
et al. 2009; Topouzis and du Guerny 1999).
There is a pronounced need to link academic
research with policy and intervention programs
especially for monitoring and evaluation.
use in report writing and decision-making.
The calls for better integration between
academic researchers, policy makers and
implementation personnel should be heeded.
Spatially, we focused on sub-Saharan Africa
and found peer-reviewed original research
articles from many countries, but given the
number of countries in sub-Saharan Africa and
the variations in ecological, cultural, political
and socio-economic regions with countries,
clearly the spatial coverage of research needs
to be expanded.
We artificially segmented the research needs
into four categories but do not imply that these
categories are isolated from one another. The
categories include three “topic areas” requiring
additional research, and one major challenge
to conducting and comparing research studies:
the issue of scale. We address the research
needs within the following categories.
The most glaring lack of research is studies
that have a longitudinal focus with repeated
measures over several years. Additionally,
few of the studies utilize sufficiently robust
comparison groups or randomized designs.
Snapshot information gives a quick glimpse
of issues, but without long-term follow-up
the view is likely distorted, especially when
dealing with ecological, health-related, and
socio-economic conditions that are in a
state of flux. The lack of spatially broad,
longitudinal data leads many writers to issue
grand generalizations based on information
that is likely heavily constrained by specific
time and place acquired data. Many of these
generalizations make ‘sense’ but are not
backed up by evidence, and may not truly
function as universals. For instance, as shown
in several papers on land tenure, although loss
of land tenure due to AIDS mortality appears to
be the norm, there are places where rules are in
effect to guarantee that land is not lost.
Remember that these categories are somewhat
arbitrary and are used for organizational
purposes only. In this section we describe
specific calls for research found in the
literature review. These will be distilled into
recommendations in a later section.
HIV/AIDS, Natural Resource Use,
and Livelihoods Research Needs
Perhaps the most often cited area of research
need is the issue of clarifying the relationship
between HIV/AIDS and livelihood security,
including dependence on natural resources
and the impacts of natural resource use on the
environment, biodiversity, and conservation.
We identified four general categories needing
additional research under this heading. The
general categories that we identified in this
category are loosely based upon four critical
categories suggested by Barany et al. (2005).
With respect to natural resources use, there is
much agreement as to the pathways through
which HIV/AIDS can result in overuse and
damage of various resources such as timber
and medicinal plants. What is glaringly lacking
27
Interactions between HIV/AIDS and the Environment
Traditional medicine and natural resource use
Anecdotal reports of natural resource use abound
but there is an urgent need to quantify the
amount and type of use and the magnitude of
effects on the resource being used (Oglethorpe
and Gelman 2008). Until there is much better
documentation and quantification of the type and
extent of natural resource use, the direct effects
of the HIV/AIDS pandemic on biodiversity will
remain unclear (McGarry and Shackleton 2009).
More research is needed on the use of
natural products and traditional medicines
used to treat HIV/AIDS and the symptoms of
opportunistic infections. Based on case study
research in Malawi and Mozambique, Barany
et al. (2005) identified various research needs
ranging from the specific, e.g., interactions
between Annona senegalensis (a Vitamin A
rich fruit) and ARVs, to the more general such
as investigating whether natural resource use
is different where the use occurs largely in
commercial private-sector managed forests
such as in South Africa, Swaziland, and
Zimbabwe, than in most countries that have
mostly publicly-managed forests. (Oglethorpe
and Gelman no date) note the need for
continued research on medicinal plants.
De Souza et al. (2008) call for documenting
traditional ecologic knowledge and additional
information on cultivation and use of traditional
medicinal plants.
There is also a lack of rigorous research
addressing HIV/AIDS and conservation or
natural resource use and management. (De
Souza et al. 2008) specifically call for research
addressing trends in natural resource use
including fuelwood, charcoal making and bush
meat trade, and for documenting best practices
that can be replicated and/or modified in other
settings. Identifying alternative materials where
resources are known to be used unsustainably,
such as timber for coffins in Kisumu, Kenya, is
critical for protecting resources (Dwasi 2002).
Barany et al. (2005) call for more focused
research on the differential use of natural
resources by specific population groups, e.g.
widows, orphans and the elderly. Oglethorpe
and Gelman (2008) urgently call for research to
quantify the impacts of HIV/AIDS on land, natural
resources, and environmental organizations,
while also implementing interventions focusing
on HIV/AIDS and environment from a gender
perspective, in the field and at policy level.
Socioeconomic effects, livelihoods, and
coping strategies
The rural poor in general are dependent on
natural resource-based livelihoods. It can
be difficult to identify coping strategies and
socioeconomic impacts that are specific to HIV/
AIDS-affected households and not to poorer
households in general or those affected by
other chronic diseases. Households that lack
resources often turn to ‘free’ natural resources to
meet their daily needs. The interactions between
natural resource-based livelihood strategies
and other forms of coping strategies and social
safety nets in relation to both HIV/AIDS and to
poverty is an area needing additional research
(Barany et al. 2005; De Souza et al. 2008).
Torell et al. (2006) report an increase of women
bartering sex for food or money in five of the
eight coastal villages studied. Research to
improve understanding of the tremendous
gender inequality that currently exists in many
areas is necessary to understand the root
causes of risky sexual behavior, the HIV/AIDS
epidemic and poor health in general, and
unsustainable resource use.
To the extent possible, differences in types and
amounts of natural resource use and livelihood
coping strategies between HIV/AIDS-affected
households and non-affected households need
to be clarified. Hunter et al. (2008b) provide
an enticing glimpse into differential household
use of natural resources when faced with the
death (from any cause, not just HIV/AIDS) of a
productive adult member. They partitioned use
into categories of deciding which resource to
select, how much of that resource to use, and
acquisition questions such as who will collect the
resource, how will it be collected and where will it
be collected. More work is needed in this arena.
We found little mention in the literature on
the role of the livestock sector in terms of its
importance for agricultural development, food
security, and trade in the country/region and
how it is affected by HIV/AIDS. One paper (Engh
et al. 2000) recommends more research to
assess the relationship between livestock and
HIV/AIDS. This study from Namibia raises many
researchable questions including documenting
the effects of increased human medical costs
on selling livestock or slaughtering them for
funerals, how care and management of livestock
is affected by HIV/AIDS incapacitation and
28
Interactions between HIV/AIDS and the Environment
loss of adult knowledge, how the inheritance
system deals with livestock, and how livestock
production is affected by loss of extension staff.
(Barnett et al. 1995) also mentioned livestock
ownership as a buffering factor in the effect
of HIV/AIDS on livelihoods. Another relatively
unstudied area is the effect of HIV/AIDS on
livelihoods of pastoralist societies (Topouzis and
du Guerny 1999).
Additional research on the costs and benefits of
existing, successful inter-agency partnerships,
such as one in Uganda between an AIDS
group, an agricultural research group, and a
women’s group to address food insecurity in
HIV/AIDS settings (De Souza et al. 2008) is
needed in different development sectors to
facilitate policy- and program-related decision
making and to persuade agencies to internalize
partnership management roles and practices.
On a more human level, we do not know what
long-term social, economic, environmental,
and psychological effects will arise from the
orphaning of millions of children (Gillespie and
Kadiyala 2005).
Ellis and Allison (2004) address diversification
of livelihoods in poverty settings and also
identify research needs that have application
to HIV/AIDS affected households specifically.
Major research questions include how:
Management, governance and markets
There are structural/policy related issues that
either arise from or influence the effects of
HIV/AIDS on different sections. Workforce
loss is frequently raised as a growing
concern in natural resource and conservation
organizations, but there are few documented
numbers available. Information is needed on
the magnitude of loss within conservation
organizations and other sectors regarding
actual costs and loss of institutional knowledge
(De Souza et al. 2008; Gelman et al. 2005;
Hemrich and Topouzis 2000).
•
land tenure reform affects the poor’s
access to land
•
taxation and business licensing affects
the poor’s incentive and ability to develop
income generating activities
•
migration and remittances affect people’s
access to natural resources, and
•
livelihoods diversification affects
community based natural resource
management.
Migration and land tenure
As noted in the literature review above, there
are a variety of ways in which land tenure
issues arise in HIV/AIDS cases and research is
needed to better understand site-, gender- and
age-specific context (Aliber and Walker 2006;
Drimie 2003; Kiai et al. 2002). The disposition
of land after adult owner death is often cited
as strongly affecting AIDS widows. Loss of
land may necessitate migration to find other
ways to survive. Frank and Unruh (2008) noted
differences in the ability of early arriving vs.
later arriving migrants to access land tenure
and their use of HIV/AIDS as a factor ‘entitling’
them to land. They argue that there is a need to
look for nuanced responses in various settings
based on perceptions to fully understand the
many ways that HIV/AIDS affects land tenure.
De Souza et al. (2008) identify several
management and governance issues that will
benefit from additional research. Identifying which
types of past or on-going integrated projects
and programs have had the most successful
and sustainable outcomes will help guide future
integrated approaches. It is also fruitful to assess
the integrated model of extension delivery and
determine the effectiveness of partnership
activities coordinated at sub-country and district
levels. Determining the actual costs and benefits
of up-front budgeting for partnership activities
and having dedicated administrators for building
and sustaining partnerships is necessary for
comparing this to other models of meeting
integrated institutional or programmatic goals.
Creating national level umbrella programs
under which integration is encouraged would
facilitate accomplishment of the above activities.
Identifying areas where policies are in conflict
or hinder integration will allow for policy
improvement. Concrete information is lacking
on how agriculture and other livelihood systems,
policy and practice contribute to the spread of
HIV in urban as well as rural areas (Gillespie and
Kadiyala 2005).
Climate change-related research
needs
A second major area in which authors have
identified a pressing need for additional
research is that of climate change. There is an
increasing awareness that changing climates
29
Interactions between HIV/AIDS and the Environment
Additionally, McMichael et al. (2003) call for
research to document baseline relationships
between climate and health, early evidence for
climate change, and scenario-based predictive
models on health pathways.
will aggravate many health, environment and
social problems including HIV/AIDS (Gommes
et al. 2004). Continued documentation of
actual and potential risks of climate change
to health, livelihoods and vulnerabilities
needs to continue (Besada and Sewankambo
2009; Costello et al. 2009; Daily and Ehrlich
1996; Frumkin and McMichael 2008; UNICEF
Innocenti Research Centre 2008).
Longitudinal studies and identification of
economic and social indicators and trends
related to climate change are a necessity,
as are age and gender specific information
(UNICEF Innocenti Research Centre 2008).
As in the other topics discussed in research
needs, strengthening of information,
technological and scientific capacity in
developing countries is crucial (Costello et
al. 2009). In so far as climate change and
health affect and are affected by sustainable
development, more research on synergies
among the three is also warranted (Halsnaes
and Verhage 2007).
Food insecurity, linkages between HIV/AIDS
and climate change-sensitive infections,
and population displacement are plausible
hypotheses of how climate change will affect
HIV/AIDS, but are more conjectural than
scientific (UNEP UNAIDS 2008). The effects
of climate change on health will be spatially
inconsistent and information is needed on
local effects to improve local programmatic
mitigation (Lotze-Campen and Schellnhuber
2009). More information is needed on seeds
and crops that will perform in new climatic
settings (IRG-USAID 2008). Many documents
including (UNICEF Innocenti Research Centre
2008) list proposed strategies for adapting
to climate change and reducing vulnerability,
but there is little evidence-based research
on which are most likely to be successful.
Lists of climate change adaptation strategies
seldom go beyond the intuitively obvious.
There is a lack of understanding of the
process of adaptation to predicted climate
change, of the decision making process
including the roles of various stakeholders,
and of barriers and constraints including
costs that limit adaptation to and mitigation
of climate change (Confanlonieri and
McMichael 2007).
Health and transmission-related
research needs
It is well beyond the scope of our expertise or
the needs of this report to address all research
needs related to health and transmission of
HIV, but there are some intersections where
information from health-based research will
inform practices and outcomes in the HIV/AIDS
and environment arena.
Although various studies have found a link
between food insecurity and risk behavior,
especially transactional sex, few have
used validated scales or been longitudinal.
Longitudinal research is also needed on
the role of food insecurity on immunologic,
virologic and mortality outcomes. Increased
evaluation on the effect of targeted food
assistance and sustainable livelihood strategies
on HIV/AIDS transmission, treatment and
outcome is also needed (Anema et al. 2009).
Research on the aforementioned topics
should also look at differential responses by
age, gender and socio-economic-cultural
background (Oglethorpe and Gelman 2008).
Food insecurity as it relates to mother to child
transmission and the mechanisms through
which food insecurity might increase the risk of
mother to child transmission are also needed
(Anema et al. 2009).
Major challenges in research for quantifying
and predicting health effects due to climate
change include issues of scale and clarification
of the usually complex, multifactoral, and
indirect causal pathways (McMichael et al.
2003). Costello et al. (2009) call for research on
five climate change/health topics:
•
documentation of climate change risks to
health and vulnerabilities
•
health protection strategies
•
health co-benefits of carbon dioxide (CO2)
reduction
•
decision support systems for climate
prediction (region specific), and
•
financial cost estimates.
Research on anti-HIV plant substances should
undoubtedly be encouraged (Cos et al. 2004).
More research is needed on the efficacy
of traditional medicines, especially as they
30
Interactions between HIV/AIDS and the Environment
affect anti-retroviral treatment. In addition,
documentation and dissemination of nutritional
values of common and/or overlooked native
foods is lacking (Barany 2003), but could play
an important role in improving health status.
Tourism, often seen as a mechanism to
improve livelihoods, may also contribute to the
spread of HIV/AIDS via workforce mobility, sex
tourists, and alcohol and drug use in vacation
setting. However, there is scant research on
the relationship between tourism and HIV/
AIDS prevalence and transmission (Ngoti and
Baldus 2004).
Issues of Scale
One of the major issues associated with
conducting research on the links between HIV/
AIDS and the environment is that of scale.
Understand the role of the environment on HIV/
AIDS or vice versa often requires information
gathered at relatively large spatial and temporal
scales. Few studies are conducted at such
scale. Simple summing of multiple, smaller
scale studies does not work where there are
feedbacks, compensations, and synergies.
Data on population, health, and environment
(PHE) are often incompatible and incomparable
because of differing scales of data collection.
The effect of HIV/AIDS on individual household
decision-making that affects the environment
and land use is difficult to discern from aggregate
data on prevalence and extent of infection
(Hunter et al. 2008b). Issues related to stigma,
unwillingness to know or declare HIV-status, and
privacy complicate fully rectifying this gap.
Another issue is the lack of longitudinal data
on virtually every topic of research relating
to HIV/AIDS and the environment. Spatial
and temporal data need to be collected on
resource use, coping strategies, livelihood
diversification, and institutional effects, as they
relate to HIV/AIDS and the environment.
An interesting observation is that most of the
research on adult mortality has focused on
the individual or household level. Few studies
addressed the effect of adult mortality at the
community level (Drimie and Gandure 2005;
Jayne et al. 2006). There is a distinct lack of
information examining why some communities
are more resilient to adult mortality than others
(Jayne et al. 2006).
Interactions between HIV/AIDS and the Environment
A Conceptual Framework for Linking HIV/AIDS and
the Environment
After evaluating the literature, we have
developed the following conceptual framework
for illustrating the complex interactions
between HIV/AIDS and the environment.
Figures 1, 2, 3, and 4 demonstrate the
most important linkages at the community
and household levels, the connections
between climate change and the HIV/AIDS
pandemic, and the workforce effects of HIV
at the institutional level. The diagrams were
developed based on both the themes emerging
from the literature review and a number of
helpful conceptual frameworks developed
by other authors (see also, Barany 2003;
Torell et al. 2007; Ezeaku and Davidson 2008;
McMichael et al. 2008b; Parker et al. 2009.
affect all aspects of the HIV/AIDS/AIDSenvironment nexus: social disruption, poverty
and gender inequality. These three factors are
intimately linked to one other and are the start
and end of a negative feedback loop in the HIV/
AIDS and environment cycle.
We consider poverty to be the keystone of
these three factors, that is, the factor which
if altered will propagate the most important
effects throughout the system. We define
poverty in the broadest terms, not just as
lack of money but also as the lack of access
to information and resources with which to
address basic human needs. The Universal
Declaration of Human Rights states that
nutrition, water, sanitation, shelter, education,
and health are basic requirements of human
well-being, and we argue that health is
dependent on the sufficient presence of all
of the other rights. Poverty can generate
conditions of food insecurity, inadequate
water and sanitation, poor health and a
multi-disease health burden, lack of access
to public goods such as education and
health care, and tenuous property rights. The
impoverished, because of the burdens of these
Upstream Factors: Poverty, Gender
Inequality, and Social Disruption
Based on the tenets of prevention from the
health arena and of addressing causal factors
(ultimate) rather than symptoms (proximate) in
the environmental literature, we have identified
three major upstream factors (Figure 1) that
“Cultural” practices
Global scale issues:
e.g. climate change, urbanization, globalization,
macroeconomics
Food insecurity
Social
disruption
Inadequate shelter
Inadequate water and
sanitation
Increased
vulnerability
to HIV
Insufficient or unequal access
to household assets (including
land)
Poverty
Lack of access to health
services
Lack of education
Decreased
coping
ability
Via: labor shortage, land tenure
issues, loss of traditional
knowledge, changing land use
practice, decreased food yields
Land tenure insecurity
Loss of social controls
Gender
inequality
Migration/mobility
Poor health, multi-disease
burden
Power dynamics
Increased reliance
on natural
resources
Risk behaviors
Safety/security issues
Via: resource
degradation,
unsustainable
usage
Figure 1: Linkages between HIV/AIDS and the environment at the community level
32
HIV/AIDS
Interactions between HIV/AIDS and the Environment
Coping Ability: The Key Factor
multiple stressors, have a decreased coping
ability for meeting basic needs. Poverty is
furthermore often “hereditary,” with children of
impoverished parents unable to climb out of
the poverty trap because of the disadvantages
in terms of access to health and health
services, education, and information into which
they were born. The connections between HIV/
AIDS and the natural environment assume a
backdrop of poverty. Pervasive poverty “sets
the stage” for the vicious interactions between
the pandemic and the environment.
Coping ability is a linchpin in the flowchart
of Figure 1. We conceptualize decreased
coping ability as the key step mediating
between the upstream determinants of social
disruption, poverty, and gender inequality,
and the downstream effects of HIV infection,
increased reliance on natural resources, and
environmental degradation.
Coping ability is resilience, capacity for
adapting to changes, and ability to recover
after a disturbance. Decreased coping ability
means vulnerability to every kind of insult,
including HIV infection. That is, people affected
by poverty, food insecurity, landlessness,
lack of access to resources and services,
oppression, pervasive inequalities, and the
atrocities of war are in every way less able to
deal with problems of every sort. Coping ability
is affected by social and individual capital and
reflects economic, psychosocial and physical
resilience to adverse events.
Like poverty, gender inequality is an upstream
determinant of the both the HIV/AIDS
pandemic and of the pernicious interactions
that connect HIV/AIDS and the natural
environment. It is a condition upon which these
connections are predicated, and, like poverty,
represents one of the ultimate causes of both
the epidemic and of the vicious cycles. Gender
inequality takes many forms, including:
•
Lack of access of women and girls to
income, education, resources, information,
adequate nutrition, water and sanitation,
and health services
•
Women and girls’ heavier burden of health
problems and safety and security issues
•
Power differential in sexual relationships, and
the expectation that women will be passive
and ignorant in matters relating to sex.
HIV/AIDS does not occur in isolation. It
flourishes in conditions of underdevelopment
and inequality, as do nearly all infectious
diseases and social ills. The boxes in Figure 1
for “increased vulnerability to HIV” and “HIV/
AIDS” could just as easily be replaced with
“diarrheal disease,” “teen pregnancy,” or
“childhood mortality.”
•
Discriminatory “cultural practices” such as
early marriage, famine marriages, female
genital cutting, and widow inheritance that
can endanger women and girls
Like poverty, this inequality predisposes
women to be less able to cope with
vicissitudes, be they economic, psychosocial,
physical, or environmental.
The increased pressures wrought upon people
by social disruptions, poverty, and gender
inequality make them more vulnerable to HIV
infection and also make them less likely to be
able to deal with—cope with—the negative
outcomes of HIV/AIDS.
A Vicious Circle
Social disruption, in the form of conflict,
migration, and the loss of social controls, is
another important upstream factor affecting
the interactions between HIV/AIDS and the
environment. HIV/AIDS flourishes in conditions
of inequality, lax social controls, conflict, and
mobility. Likewise, systems out of control
are likely to foster environmental disruption.
As traditional structures that govern human
interactions and use natural resources erode,
communities are less likely to be able to cope
with everyday needs. People affected by war,
landlessness, or forced migration are already
especially vulnerable and susceptible to HIV.
As we see it, the interaction between HIV/AIDS
and the environment hinges upon the vicious
circle contained in the right-hand side of Figure
1. This cycle is predicated upon the upstream
effects of poverty, gender inequality, and
social disruption, and begins and ends with
decreased coping ability.
Decreased coping ability makes people and
communities more vulnerable to HIV/AIDS. HIV/
AIDS in turn leads to increased dependence
on natural resources, as households lose labor
force, land tenure, and traditional knowledge,
33
Interactions between HIV/AIDS and the Environment
coping, can lead directly to increased reliance
on the natural environment, bypassing
HIV infection, and creates a second selfreinforcing loop. Teasing out the effects of
poverty and the effects of HIV/AIDS on natural
resource consumption and its environmental
effects is addressed in this report as a future
research priority.
and are less able to maintain their previous
livelihoods. This increased reliance on natural
resources in turn makes communities even less
able to cope, as they become more and more
exposed to the vagaries of nature, weather,
and availability of resources. Infection with HIV/
AIDS also itself decreases coping ability, which
may lead to both behavior that increases HIV
transmission and also increase natural resource
use. The cycle is self-reinforcing and reciprocal.
Zooming In: Connections at the
Individual Level
Furthermore, these downstream “effects,”
in turn, feed back into the three upstream
determinants—poverty, social disruption, and
gender inequality. Because increased reliance
on natural resources may lead to unsustainable
land use and resource degradation, it forms
a feedback loop, increasing poverty and
again decreasing coping ability. HIV infection
likewise feeds back, generating more social
disruption as institutions continue to erode,
contributing to increased poverty, and
reinforcing gender inequality, as women are
overrepresented among the HIV-infected and
–affected. Intergenerational poverty, as AIDSorphans are left with few resources, is another
compounding factor in this vicious circle.
The dynamic discussed above and detailed in
Figure 1 focuses primarily on the community
level. We will now “zoom in,” to examine the
connections between HIV/AIDS and the natural
environment at the individual or household
level, depicted in Figure 2.
As with the community-level interactions, the
individual/household interactions between HIV/
AIDS and the environment are characterized by
interconnecting feedback loops.
Let us start at the center of the diagram, with
HIV vulnerability, transmission probability,
and morbidity. As discussed elsewhere, these
are conditioned by lack of health services,
multi-disease burden, and malnutrition,
as well as by the risk behaviors necessary
for acquiring the virus. Nutrition, in turn,
It is also important to note that the vicious
cycle can be completed without ever involving
HIV infection. As illustrated by Figure 1, a
direct path from poverty, through impaired
Land tenure
insecurity
Loss of traditional
knowledge
Multi-disease burden
AIDS
mortality
Labor shortage
Risk behaviors
Lack of access to
health services
Migration
HIV
vulnerability
transmission
probability
morbidity
Malnutrition
Lack of household
resources
Food and water
insecurity
Decreased agriculture output
Increased natural resource use
Decreased purchasing power
Figure 2: Linkages between HIV/AIDS and the environment at the household level
34
Interactions between HIV/AIDS and the Environment
Zooming Out: Connections to
Global Environmental Change
is determined in part by food and water
security, for which households depend upon
agriculture, natural resources, and purchasing
power. If a household lacks resources (e.g.,
capital, knowledge, land, livestock), it will be
unable to maintain a livelihood, and therefore
unable to provide food and water security for
itself, making its members more vulnerable
to malnutrition, and therefore to HIV infection
(among other ills).
As we see it, global environmental change—
“climate change”—will have important and
wide-ranging effects on the relationship
between HIV/AIDS and the environment, and
it is therefore important to examine these
interactions on a larger scale.
Figure 3 shows the vicious cycle between
climate change and its immediate effects,
decreased coping ability, increased HIV/
AIDS, economic instability, increased natural
resource use, and environmental degradation.
As in Figure 1, discussed above, this cycle
takes place against a background of social
disruption, poverty, and gender inequality.
Stepping back in the cycle, lack of household
resources can be conditioned by migration,
lack of labor availability at the household
level, and landlessness. These conditions, in
turn, are deeply affected by HIV/AIDS illness
and mortality.
Loss of traditional knowledge through HIV/
AIDS mortality also directly affects livelihood
mechanisms such as agriculture and natural
resource collection, and feeds back into
a lack of household resources. Lack of
household resources can lead to migration,
risky behaviors (such as commercial sex),
and back to HIV vulnerability, completing the
vicious circle.
The effects of climate change on the natural
environment, including biodiversity loss, natural
disasters, precarious food and water security,
and an increase in vector-borne disease, will
certainly have an impact on human health and
well-being (McMichael et al. 2003). Through
increased poverty, social disruption, forced
migration, and conflict, the effects of climate
change will further weaken communities’ and
households’ coping ability, predisposing them to
HIV vulnerability, risk behaviors, and infection. As
discussed previously, HIV/AIDS then produces
increased natural resource use through labor
shortages, loss of traditional knowledge, etc., and
natural resource use can feed back to generate
additional climate change, through degrading the
land and natural resources.
Note that environmental degradation is not
included in Figure 2, because this diagram
focuses specifically on the individual/household
level, and large scale degradation occurs with
an aggregation of households and multiple
pressures on the environment.
Changes in
biodiversity
Changes in
ecosystems
services
Climate
Change
Natural disasters
Water insecurity
Via social
disruption,
conflict,
migration,
increased
poverty
Decreased
Coping Ability
Risk
behaviors
Food insecurity
Increased vectorand water-borne
disease
Changes in land
use practice
Increased
natural
resource use
Food and water
insecurity
Environmental
degradation
Figure 3: Effects of climate change on the links between HIV/AIDS and the environment
35
HIV/AIDS
Interactions between HIV/AIDS and the Environment
Institutional Effects of HIV/AIDS
on Conservation/Environmental
Organizations
perform these tasks can result in an increase in
overharvesting and other illegal activities that
degrade the protected resources. There may
also be a loss of up-to-date information on
status of the resources and funding diversions
to other activities such as HIV treatment that
affect protection of the resources.
Figure 4 illustrates effects of HIV/AIDS on
conservation/environmental organizations.
Because protected areas are often in remote
regions, personnel are frequently posted for
long periods of time away from their families
and rotated from site to site. This coupled
with the lack of HIV awareness or access to
condoms can increase the risk of HIV infection.
Staff members who become HIV-positive or
have family members who are infected are less
available or less capable of performing their
duties. Organizational productivity drops due
to loss of leadership and trained professionals,
loss of institutional memory, and low morale.
These losses in turn decrease the ability of the
organization to perform programmatic tasks
such as research, law enforcement, tourism,
protected area management and community
work. Inadequate performance of or inability to
Tensions
When we began to discuss the way forward
after having reviewed and evaluated the
existing evidence on the interactions between
HIV/AIDS and the environment, a number of
salient tensions arose.
•
There is a tension between acknowledging
that upstream determinants (ultimate,
rather than proximate factors) are
absolutely key to stemming the problems
associated with HIV/AIDS and the
environment, while conceding that
the proximate factors are more easily
actionable and researchable. The upstream
Risk factors
station far from family
mobile men
lack of health resources,
condoms, etc
Illness and
death
Decreased labor availability
and quality
Via caregiving
responsibilities,
funeral attendance
HIV/AIDS
absenteeism
lost “resource” of trained staff
Shift in
funding
Reduced ability to perform
programmatic tasks
research
law enforcement
tourism
protected areas management
community work
Decreased Productivity
institutional memory
leadership
morale
Environmental consequences
overharvesting
illegal activities
Figure 4: Institutional level linkages between HIV/AIDS and the environment within conservation/environmental organizations
36
Interactions between HIV/AIDS and the Environment
determinants of the interactions between
HIV/AIDS and the environment—poverty,
social disruption, and gender inequality—
are beyond the scope of any one agency or
government’s purview, but are nonetheless
critical to address, and have been shown in
population-based epidemiological studies
to affect HIV/AIDS prevalence profoundly.
Interventions addressing the proximate
causes are less verified in the literature as
being effective, but have traditionally been
the focus of HIV-prevention campaigns
because of their practicality.
•
A disciplinary tension between public
health and the environmental sector also
exists. The priorities of public health
organizations may differ from, and even
conflict with, those of environmental
organizations. For instance, the public
health literature glows about the benefits
of wild foods as nutritional supplements
for people living with HIV/AIDS, while the
environmental literature worries about the
biodiversity effects of wild food collection.
What one field may see as an opportunity,
the other may perceive as a threat.
•
A tension between site-specificity and
replicability/comparability of research
and interventions is another issue.
Most research and implementation of
interventions addressing HIV/AIDS and
the environment has been relatively
small-scale, and has been highly
contextualized by the local geographical,
cultural, agricultural, and epidemiological
climate. While this is usually appropriate
scientifically or programmatically, it makes
for challenges in comparing or replicating
studies or interventions in other settings.
Interactions between HIV/AIDS and the Environment
The Way Forward: Recommendations
Recommendations Discussed at Collaborator’s Meeting, 5 March 2010
A planning meeting identifying next steps in
moving forward with an HIV/AIDS and the
Environment Program between the University
of Washington and partners in Africa was held 5
March 2010 at the IUCN-ESARO headquarters
in Nairobi, Kenya. Twelve persons attended,
representing the University of Washington,
University of Nairobi, IUCN (ESARO and the
Uganda Office), the International Planned
Parenthood Federation (Africa Region) and the
East African Wildlife Society. Introductions were
made, followed by brainstorming sessions on
research topics and intervention action of interest
to the group. A priority matrix voting system
was used to identify the consensus priorities in
research and interventions. The group expressed
a strong desire to avoid research for research’s
sake. The following general research topics were
identified, discussed and then prioritized as
indicated below.
and rainfall for farming. How are the areas
with better natural resources or increased
employment opportunities being managed
to mitigate increased susceptibility to HIV?
How has the influx of migrants affected
natural or social resources in the areas
receiving them? Try to control for the effect
of poverty vs. effect of HIV/AIDS on those
migrating.
4. Conduct policy analysis to identify where
policy is creating negative effects on HIV/
AIDS-environment interactions and identify
ways to neutralize such policies. This includes
both protected areas and agricultural areas
as affected by governmental policies. How do
the policies affect susceptibility to HIV and/
or protection of natural resources? Include
consideration of increased interest in payment
for environmental services. How can those
services be quantified, who will pay and who
will receive? Also what effect is consideration
of climate change having on policy?
Priority Research Topics in Order of Interest
1. Compare prevalence and interactions
between HIV/AIDS and the environment
across different types of conservation areas:
governmental, private, and community
based protected areas. This includes HIV/
AIDS effects on workforces protecting
and managing the areas, use of local
households (with and without HIV) of
resources in and around the protected
areas, status and trends of resources within
and near the protected areas, responses
of management agencies to HIV/AIDS, and
financial costs to agencies related to HIV/
AIDS including replacement of trained staff
and the effect of the environment on HIV/
AIDS, e.g. access to and use traditional
medicines and wild land foods.
5. Track funding streams in the conservation,
climate change and HIV/AIDS arenas. Are
funds being diverted from one category to
another? Do funds for a topic reflect policies
in place concerning that topic?
Intervention priorities
1. Develop a collaborative group with a
designated coordinator to facilitate
integration, dissemination of information,
and keep interested parties informed of
activities and advances in the HIV/AIDSenvironment arena. Build a consortium
consisting of UW, UoN, IUCN-ESARO,
IPPF-ARO, SCC/VI Agriforestry and East
African Wildlife Society as the initial core
group. Consider adding other partners at
a later date. Establish a secretariat and
assign responsibilities and roles in moving
the project forward. Formalize relationships
between organizations; partnerships
are currently loose and dependent on
individuals’ interest in collaboration. Make
collaboration an institutional responsibility.
This collaborative group will ideally provide
structures, skills, and human resources, and
seek funding for moving forward with joint
projects in research and/or implementation
of interventions.
2. Use district level data on status of
environment and prevalence of HIV/AIDS to
identify relationships between environmental
condition and prevalence. Do high quality
environmental conditions and availability or
unavailability of natural resources correlate
with reduced prevalence of HIV/AIDS?
3. Investigate migration impulses to areas of
abundant resources, including employment
from development projects such as roads
and ports and the cut flower industry as well
as protected areas or areas with better soils
38
Interactions between HIV/AIDS and the Environment
2. Conduct efficacy, effectiveness, and
operations research on existing models of
implementing integrated HIV/environment
interventions, seeking evidence-based,
practical interventions for scaling up and
disseminating. Systematically test existing
integrated interventions to understand
the most critical steps and principles in
implementation. Form a set of guidelines
for integrating HIV/AIDS and environment
projects, then test and modify it. These
guidelines could then be used for scaling
up evidence-based interventions at the
regional level. Examples of models to be
tested included community ecotourism,
environmentally based income generating
activities (IGAs), and comparisons of
parallel interventions in urban and rural
settings. Essentially, seek out the most
successful interventions and practices for
scaling-up and disseminating.
and should be encouraged by forming
virtual or physical libraries or resource
centers. Experience-sharing should
also ideally help to minimize duplication
of effort and to allow for partnerships
between organizations working in similar
geographic or programming areas.
Encourage workshops or site visits
between organizations to disseminate
success stories. On a related note,
strengthen and reinvigorate the national
level networks that already exist for PHE.
Recommendations from Literature
Review and Site Visits in Kenya
We agree that the recommendations that came
out of the collaborator’s meeting (detailed above)
are fruitful avenues for addressing the linkages
between HIV/AIDS and the environment. Below,
we present several additional areas of research
and intervention that were prominent in the
literature that should be pursued.
3. Build capacity at the local level. While
many organizations have seen enthusiasm
at the community level for addressing
the HIV/AIDS epidemic in conjunction
with conservation or environmental
issues, capacity for doing so is lacking.
Conservation organizations typically do
not have staff well versed in HIV/AIDS
issues and health organizations typically
do not have expertise in conservation.
A number of highly motivated groups
(such as community conservation
groups and HIV/AIDS support groups)
have already been mobilized, and there
is a consensus that capitalizing on the
strengths and momentum of these groups
will help to move integrated projects
forward. Capacity building, in the form of
information/experience sharing, additional
training, and sensitization is needed at the
level of the community-based organization
(CBO). Likewise, organizations, including
those at higher levels such as government
and policy-making bodies, need
additional training and capacity building
on integrating projects. Developing a
standardized curriculum and training
trainers to build capacity on integration/
mainstreaming is a priority.
Monitoring and Evaluation is Critical
Monitoring and evaluation (M&E), including
development of standardized variables,
measures, methodologies, and indices,
is a fundamental principle for research or
implementation. Without comparable data
and methods, it is difficult to assess spatial,
temporal, environmental and cultural differences
among studies. In addition, implementation
science (also known as operations research)
is urgently needed, as is work “translating”
research and policy to action.
In the research arena, there are a number
of subject areas in which development of
standardized measures would be useful. Explicit
monitoring of the effects that poverty alleviation
projects have on ecosystems and their services
is needed along with multidisciplinary science
to identify cost-effective solutions (Sachs et
al. 2009). Standardized measures for a variety
of factors regarding food insecurity are also
needed, as effective assessment of the role of
food insecurity in health and HIV/AIDS depends
on measurable, repeatable and agreed-upon
indicators. This includes measures to address
various components of food insecurity such as
quantity, quality, safety and socially-appropriate
methods of procurement of food, validated
short questionnaires to assess levels of food
insecurity, and operational assessments to
determine effectiveness of interventions (Anema
et al. 2009).
4. Form networks of interested HIV- and
environmentally-focused CBOs and
create a clearinghouse or resource center
for information sharing. This kind of
experience-sharing is valuable at both
the local level and at the national level,
39
Interactions between HIV/AIDS and the Environment
We have developed the following list
of common problems in developing an
appropriate monitoring and evaluation system:
•
•
•
•
Baseline data are often lacking, making the
outcomes and impacts of any intervention
difficult to measure.
There is a need to streamline M&E
systems. Program implementers are often
burdened with multiple, different reporting
systems for each funder, project, or sector.
Simultaneously, there is a need to hew to
accepted plans and indicators within a
field or for a particular donor. Sometimes
conflicting plans or indicators from various
donors must be juggled.
There is a lack of appropriate, valid
indicators that accurately measure what
the program is achieving. Indicators for
successful monitoring and evaluation must
be (Finn 2007):
•
Valid – accurately measuring a
behavior, practice or task;
•
Reliable – consistently measurable in
the same way by different observers;
•
Precise – operationally defined in
clear terms;
•
Measurable – quantifiable using
available tools and methods;
•
Timely – providing measurement at
time intervals that are relevant and
appropriate for program goals and
activities; and
•
Programmatically important – linked
to achieving program objectives
Monitoring and evaluation considerations
must be taken into account from the
inception of a project; it is difficult to
“go back” and include provisions for
documentation and data collection after a
project has begun.
•
Inclusiveness of stakeholders’ (both
internal and external) concerns must be
considered in developing a plan.
It is difficult to define outcomes, outputs,
and impacts, and to tease out what a
specific project or program’s effects are
when multiple interventions taking place
and background change is happening.
•
Resistance is sometimes encountered at
the community or program implementation
level to monitoring and evaluation
schemes. M&E is often seen as being
punitive or threatening. Fostering an
attitude that is receptive to monitoring
and evaluation among implementers and
partners is critical.
•
Ensuring accurate and thorough data
collection in resource-constrained settings
can be challenging.
•
There is a lack of methodology for
documenting “intangibles,” such as
psychosocial and socio-cultural effects. For
example, what role do the personalities and
backgrounds of the individuals involved in
either transmitting or receiving information
during interventions affect outcomes?
Guidance for preparing monitoring and
evaluation plans is available. USAID and
MEASURE Evaluation’s toolkit, “A Guide for
Monitoring and Evaluating Population-HealthEnvironment Programs” provides a good
starting place for thinking about developing
indicators and a plan for M&E (Finn 2007).
While the kit has been piloted, it needs to be
tested in multiple settings. Each field site has
a unique set of conditions and history, yet
consistency is needed in measurements so
that data can be aggregated across sites for
adaptive management purposes. The balance
between uniform consistency and unique
settings will be difficult to find.
Deciding on the level and aggregation of
data is a challenge. Data can be difficult
to compare across disciplines if one
discipline looks, for instance, at data on
the provincial level, while another examines
the district level, or if one disaggregates by
age and gender while the other does not.
•
•
Documenting the “added value” of integrated
interventions is a particular challenge for
convincing policy-makers and funding agencies
that integrating HIV/AIDS and environmental
interventions is worthwhile. Added value can be
economic, as in streamlining expenses, sharing
costs across sectors, and making a project
more cost effective. Added value can also
be programmatic; for instance, conservation
efforts may in fact be more effective if health
interventions are also implemented at the
community level, because of increased
community commitment to the conservation
project and decreased labor lost to illness.
40
Interactions between HIV/AIDS and the Environment
Additional Research Recommendations
•
In addition to those presented above, we
recommend the following topics as possible
areas of interest for further research on
the interactions between HIV/AIDS and
environment.
Insofar as possible, address upstream
factors of poverty, gender inequality, and
social disruption with every intervention.
•
Advocate for integration at the policy-level.
Convince policy-makers that integration is
an important principle. Use evidence-based
research and monitored and evaluated
interventions to document the added
value of integration. Use research data to
influence policy- and decision-making.
•
As mentioned in the collaborator’s
meeting, evaluate various interventions
systematically and identify best practices
for scaling up. Examples of interventions to
test include:
•
•
•
•
Determine the interrelationships between
HIV/AIDS and the upstream determinants
of social conflict, poverty and gender
inequality in terms of their effects on
ecosystems, ecosystem services and
natural resource use.
Identify and measure appropriate
ecological indicators to identify status and
trends of critical resources affected by
HIV/AIDS.
Examine and measure how resource
overuse leads to breakdown of ecosystem
function and how that leads to further food
insecurity and poor health, feeding back to
HIV/AIDS.
Create inventories of known medicinal
plants to track changes in numbers
of plants and identify areas needing
protection to avoid extirpation.
•
Pursue additional pharmaceutical and clinical
research regarding the effects of medicinal
plants and their interactions with ART.
•
Investigate the relationship between food
insecurity and HIV/AIDS outcomes (for
example, clarify the relationship between
food insecurity and the effectiveness
of ART, susceptibility to infection, and
mother-to-child transmission).
•
Improve understanding of land use/land
tenure issues. Collect additional data on
site-, gender-, age-, culture-specific uses
of land and inheritance patterns.
•
Quantify and predict food insecurity and
human health effects of climate change.
•
•
environmentally sound livelihoods
such as ecotourism and naturalresource based livelihoods
•
sustainable agriculture practices
•
alternative technologies, and
•
natural resource management
practices.
Mainstream HIV/AIDS at the institutional
level and implement internal workforcebased interventions. An organizational
policy for HIV/AIDS and measures
for dealing with the consequences of
the disease within the implementing
organization are prerequisite for
conducting any other kind of integrated
intervention and should continue at all
levels of institutions and organizations.
Integrating Interventions is a Process
Table 5 illustrates a continuum from parallel
interventions occurring in multiple sectors to
fully integrated projects. Organizations may not
be able to transition overnight from working
only in their own sector on their own mandate
to wholeheartedly incorporating messages,
techniques, and indicators from other sectors.
Any step toward integration is a step in the
right direction; the transition need not be
made all at once. Table 5 uses the specific
example of mainstreaming/integrating HIV/
AIDS or health concerns into the purview
of environmental organizations. Note that,
with minor adjustments, the direction of flow
could be reversed, indicating mainstreaming/
integrating environmental considerations into
the work of HIV/AIDS organizations.
Additionally, we recommend building internal,
national capacity for conducting research in
developing countries.
Additional Intervention Recommendations
Similarly, we have identified the following areas
of interest in implementing integrated HIV/
AIDS-environment interventions.
41
Interactions between HIV/AIDS and the Environment
Table 5: A framework for integration of environmental and health programming
Adapted from (Oglethorpe et al. 2008)
ELEMENT 1: Relationship of Environmental Organization to Health/Development Partners
Work in: Parallel
Coordinate Efforts
Integrate Efforts
Increasing operational efficiency
ELEMENT 2: Relationship of Environmental Priorities to Community Health Priorities
Barter—project addresses
community health
priorities in exchange for
community engagement
in key environmental
activities
Entry point—project
addresses community
health priorities to
generate community
goodwill towards
environmental activities
Bridge—project addresses
community health
priorities that are closely
related to environmental
priorities in hopes that
later community will
comprehend linkage to
environmental protection
Symbiotic—project addresses
health and environmental
priorities that are identical
for the environmental
organization and community,
so community goodwill
towards environmental
protection occurs organically
Increasing degree of conceptual linkage
ELEMENT 3: Level of Integration in Activities, including Communication
Activities separate
by sector
Separate activities with
integrated messages
Integrated activities with
integrated messages
Increasing degree of integration
ELEMENT 4: Level of Integration in Project Indicators and Results
Indicators and results totally
separate by sector
Indicators and results providing
some synergy and benefits to each
sector but not strongly linked
Increasing degree of integration
42
Good synergies and significant
benefits between environmental
and health sectors
Interactions between HIV/AIDS and the Environment
Summary and Conclusions
The focus of most HIV/AIDS research and
programs has been on prevention and
treatment, with an emphasis on behavior
modification. This narrow focus excludes the
broader context of the disease and ignores
some of the more ultimate, rather than
proximate causes of the epidemic. Poverty,
gender inequality, and social conflict set the
stage for enhanced susceptibility to HIV and
the increased reliance on ‘free’ ecosystem
services and biodiversity to meet increasing
household needs that arising from having to
cope with the effects of HIV/AIDS.
There has been a clear surge in the past
decade in enthusiasm, activity, and momentum
for work—both research and implementation
focused—on the links between HIV/AIDS
and the environment. We reviewed existing
literature on the interactions between HIV/AIDS
and the environment. We had not anticipated
finding as many materials, especially peerreviewed literature, on the subject as we did.
The lack of peer-reviewed citations in many
of the prominent agency documents implies a
failure to get original research into the hands
of policy makers for use in report writing and
policy development. Nonetheless, the vast
majority of the evidence remains anecdotal
and/or unreplicated. The anecdotal nature of
much of the evidence does not imply that the
conclusions reached are in error, but rather that
many of the conclusions should be validated
to provide a strong, evidence-based platform
for program development and to maximize the
return on investment in these new programs.
There is a clear need for research in more
countries, regions, and socio-ecological settings.
Research on HIV/AIDS and the environment
that extends for several years is largely nonexistent. In terms of natural resource use, it
is unclear to what extent reliance on natural
resources is driven by lack of resources in poor
households versus households affected by HIV/
AIDS. Monitoring and evaluation of projects is
lacking, which makes it difficult to identify good
practices that can be scaled-up to assist more
communities. Mainstreaming HIV/AIDS into
programmatic efforts outside of the health sector
is a step towards a more integrated approach to
HIV/AIDS and the environment.
The excitement and momentum of multiple
funders, NGOs, and other agencies wanting to
get involved in mainstreaming and in integrated
PHE or HIV/AIDS-environment programming
rings with optimism of what can be achieved
in this field. While there is promising growth in
terms of both research and implementation,
the field is still “new,” and the subject is ripe for
investigation and action. Ensuring both a strong
base of evidence and sensibly monitored and
well-evaluated interventions, however, will be
critical for the success of the field.
Interactions between HIV/AIDS and the Environment
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50
Anema, A
et al.
Baker, L
Food insecurity and HIV/
AIDS: current knowledge,
gaps, and research
priorities
Feeling the heat: Child
survival in a changing
climate
Making the connection:
AIDS and water
2009
2006
51
Non-timber forest
products in the livelihood
and coping strategies
of households and
communities affected by
HIV/AIDS
Andrew, M
et al.
Land use and livelihoods
2009
2003
Barany, ME
Ball, AM
AUTHORS
YEAR
DOCUMENT TITLE
Thesis/
dissertation
Journal case study
Non-journal
review
Journal review
Non-journal
review
TYPE OF
PUBLICATION
Sub-Saharan Africa
Zambia
Global
Global
South Africa
COUNTRY/REGION
• HIV-affected households and non-timber forest
products
• 15,000 plants are consumed in Africa
• HIV increases dependence on natural products
• Traditional med & plants over-harvesting
• Workforce issues
• Natural resources are low-input
• Case study of mainstreaming HIV into the water sector
• Climate change will affect water- and vector-borne
disease, hunger/malnutrition, weakened health systems,
livelihoods, urbanization/migration
• Gender as an important issue
• Gives policy recommendations: “climate-proofing”
systems, safety nets; recommends participatory
approach
• HIV & food insecurity interact in a vicious cycle
• High rates of food insecurity in HIV, malnutrition leads
to increased transmission, risk behaviors, decreased
immunity, decreased access to treatment and care,
decreased CD4, incomplete viral suppression, and
decreased survival; correlation between malnutrition
and poor access to health services. Women most at risk.
• Good review, nice bibliography
• Under-farming because of labor shortage (along with
other factors)
• Poorer households more likely to use natural resources
• Urban to rural migration increases natural resource
demand
• Decreasing livestock numbers as households sell off
stock to cope with HIV
• Institutional lack of capacity (HIV HR concerns) leads
to poorer land management and reform
MAJOR FOCUS
Appendix 1: Selected Annotated Bibliography (Documents marked with • indicate particularly rich sources of concepts, data, or references)
Interactions between HIV/AIDS and the Environment
2003
•
•
•
•
Meeting the challenges of
HIV/AIDS in conservation
agency workforces: A
technical guide
2010
2009
2007
52
Poverty risks and national
parks: Policy issues
in conservation and
resettlement
Shifts in African crop
climates by 2050 and
the implications for crop
improvement and genetic
resources conservation
1995
Castel-Gandolfo
Workshop: Introduction
to the impact of climate
change, economic crisis,
and increase in food prices
on malnutrition
The social and economic
impact of HIV/AIDS
on farming systems and
livelihoods in rural Africa:
Some experience and
lessons from Uganda,
Tanzania and Zambia
Cernea,
MM and
SchmidtSoltau, K
Cash,
JA and
McCool, SF
Burke, MB
et al.
Bloem,
MW et al.
Barnett, T
et al.
Journal case study
Non-journal
guideline or
toolkit
Journal research
Journal
conference
proceeding
Journal research
• Human resources guide regarding HIV for
environmental agencies
• Workforce effects of HIV epidemic include loss of
experience-based knowledge in staff, absenteeism,
change in employee abilities
Southern Africa
Central Africa - Congo
River basin
• Advocates “double sustainability” of livelihoods and
biodiversity
• Population displaced by protected areas in Central
Africa is approximately 100,000 (projected 250,000 by
2012)
• Eviction leads to: increased morbidity and mortality,
food insecurity, landlessness, homelessness,
marginalization, joblessness, and decreased access to
common property
• Majority of African countries with have more than 50%
“novel” climate by 2050
• Food insecurity leads to malnutrition, micronutrient
deficiencies, and “hidden hunger”, which in turn
decrease immunity, ART response, and worsen HIV
outcomes
• Need for a “nutritional standard of care” in HIV
treatment
• Links between HIV/AIDS and livelihoods in Uganda,
Tanzania, and Zambia
• Early paper detailing labor and economic impacts of
HIV/AIDS
Africa
Global
Uganda, Tanzania,
Zambia
Appendix 1: Selected Annotated Bibliography (Documents marked with • indicate particularly rich sources of concepts, data, or references)
Interactions between HIV/AIDS and the Environment
2006
2009
2007
•
2008
2008
•
53
web
The Impacts of HIV/AIDS on
rural livelihoods in Southern
Africa: An inventory and
literature review
The impact of HIV on rural
households and land issues
in Southern and Eastern
Africa
Conservation Refugees
Drimie, S and
Gandure, S
Non-journal
research
Non-journal
review
Non-journal
review
Dowie, M
(orionmagazine
.org/index.ph p/
articles/161)
Drimie, S
Journal case
study
DeMotts, R
Mitigating an elephantine
epidemic: Gendered spaces for
HIV/AIDS outreach through
Namibian conservancies
De Souza, RM
et al
Journal case
study
Confalonieri, U
and McMichael,
A
Global environmental
change and human
health Science plan and
implementation strategy
Using innovation to address
HIV, AIDS, and environment
links: Intervention case studies
from Zimbabwe, Uganda, and
Malawi
Non-journal
review
Challe, JF and
Price, LL
Endangered edible orchids
and vulnerable gatherers in the
context of HIV/AIDS in the
Southern Highlands of Tanzania
Journal research
Zimbabwe
Southern and
Eastern Africa
Global
Zimbabwe,
Uganda, Malawi
Namibia
Global
Tanzania
Rural impacts of HIV
Explores HIV-poverty connection in some detail
Migration, poverty-driven commercial sex,
Decreased food production
Household coping strategies
• HIV/AIDS effects on livelihoods in Southern Africa
• Coping strategies
• Identifies research gaps and suggests interventions
•
•
•
•
•
• Conservation endeavors sometimes cause forced migration;
10 million people have been displaced historically
• Orphans and vulnerable children have less access to
traditional knowledge
• Gender & natural resource use, land
• Internal workforce issues & mainstreaming
• Food security issues
• Need to document “added-value” of integrated programs
• Case studies of interventions to address HIV and
environment simultaneously
• Using conservation agencies to address HIV/AIDS
decreases stigma
• HIV/AIDS education should be “embedded” in
conservation field-workers’ duties
• Mitigation efforts must be gender-sensitive and tailored to
the local situation
• Interactions between global environmental change and HIV
• Science plan includes activities for future work
• HIV-affected people, especially orphans, increase
natural resource use, including of endangered species
Appendix 1: Selected Annotated Bibliography (Documents marked with • indicate particularly rich sources of concepts, data, or references)
Interactions between HIV/AIDS and the Environment
2002
2005
•
•
2004
2002
•
•
2004
54
Engh, I et al.
Ezeaku, PI and
Davidson, A
HIV/AIDS in Namibia: The
impact on the livestock sector
Farming as a livelihood source
for the urban poor of Nakuru,
Kenya
Journal review
Ellis, F and
Allison, F
Livelihood diversification and
natural resource access
A guide for monitoring and
evaluating population-healthenvironment programs
2000
Analytical situation of land
degradation and sustainable
management strategies in Africa
Non-journal case
study
Dwasi, J
HIV/AIDS and natural
resources management in
Africa: Findings from Kenya,
Namibia, South Africa, and
Uganda
•
Non-journal
guideline or
toolkit
Journal research
Finn, T
Foeken, DWJ
and SO Owuor
Non-journal
review
Non-journal case
study
du Guerny, J
and Hsu, LN
Environment and agriculture
interactions: Implications
for HIV and other infectious
diseases
Non-journal
review
Kenya
Global
•
•
•
•
•
Africa
• Diversification of income-sources, urban agriculture very
important for urban residents
• Urban-rural linkages key: income to rural areas, food to
urban areas common.
• “Multi-spatial” households common.
• Poorest least likely to take part in farming--lack of access
to land and capital
Sustainable land management in Africa
Brain drain
Increased natural resource use and unsustainable land use
Monitoring and evaluation needed
Good guidance for developing indicators and variables in
population, health, environment programs
• HIV-affected households sell off livestock as a coping
mechanism
• Longer-term effects unclear
• Livelihoods diversification means greater household
coping ability
• The poorest tend to be “locked in” to either subsistence
farming or dependence on common-pool natural resources
• Land-tenure and gender issues can be barriers to
livelihoods diversification
• HIV negatively affects management and conservation of
natural resources
• Issues include: workforce, financing, changes in
conservation activities, harvesting of medicinal plants,
destruction of social structures upon which CBNRM is
based, land use changes, and loss of traditional knowledge
• Provides examples/case studies of interventions
• HIV and agriculture sector interactions
• Labor force issues: time, energy, and knowledge
• Strategies for response to HIV/AIDS include labor-saving
technologies, reviving nutritious traditional crops, and
cultivating botanical medicines
• Nice synthesis, with a good bibliography
Namibia
Sub-Saharan Africa
Kenya, Namibia,
South Africa,
Uganda
Global, SE Asia
and Africa
Appendix 1: Selected Annotated Bibliography (Documents marked with • indicate particularly rich sources of concepts, data, or references)
Interactions between HIV/AIDS and the Environment
2008
2007
2008
•
2006
•
•
2008
2004
2005
2005
•
•
•
55
2005
2003
The environment, natural
resources, and HIV/AIDS
Integrating gender into HIV/
AIDS programmes: a review
paper
HIV in the fisheries sector in
Africa
HIV/AIDS and food and
nutrition security: From
evidence to action
Impact of HIV/AIDS: how can
it be anticipated and managed
Plant diversity, sustainable
rural livelihoods, and the HIV/
AIDS crisis
2008
Climate change and
public health: thinking,
communicating, acting
Agricultural biodiversity,
nutrition, and health: Making
a difference to hunger and
nutrition in the developing
world
Demarcating forest, containing
disease: Land and HIV/AIDS
in southern Zambia
Non-journal
review
Non-journal
guideline or
toolkit
Gupta, GR,
et al.
Hammarskjöld,
M
Non-journal
review
Non-journal
review
Journal case
study/review
Sub-Saharan Africa
Global
Sub-Saharan Africa
Global
Sub-Saharan Africa
Global (Africa and
SE Asia focus)
Global
Journal
commentary
Non-journal
review
Global
Zambia
Journal review
Journal research
Gordon, A
Gillespie, S and
Kadiyala, S
Gelman, N and
Oglethorpe, J
Gari, JA
Frumkin, H and
McMichael, A
Frison, EA et al.
Frank, E and
Unruh, J
• Natural resources, agriculture, and ecological
consequences of HIV
• * Workforce issues
• Overview of gender aspects of the epidemic
• trategies for incorporating gender concerns throughout
HIV/AIDS interventions
• HIV vulnerabilities of fisherfolk
• Fishers 4.4-10 times more likely to be HIV-infected than
general population. In some countries, fishers are at
higher risk than some “risk groups” such as truck drivers
and even commercial sex workers
• HIV impacts on fishing communities
• HIV and food security
• Good review, lots of case studies and examples, excellent
bibliography
• Issues facing protected areas/parks specifically in terms
of HIV/AIDS
• Human resources concerns, diversion of funding, loss of
traditional knowledge, natural resource use
• Mobilizing local resources to mitigate HIV effects
• Use of agrobiodiversity and “neglected” traditional
knowledge and crops
• Commentary: integrating public health and climate
change interventions is beneficial to both, but requires
innovation
• Analysis of traditional foods; “neglected” foods
• Food- and food-diversity based interventions are more
successful than single-nutrient based ones.
• Need to rely on indigenous knowledge taxonomic &
nutrition info re: traditional foods are needed
• HIV/AIDS affects land use, is sometimes purposefully
invoked to retain or regain control of land
Appendix 1: Selected Annotated Bibliography (Documents marked with • indicate particularly rich sources of concepts, data, or references)
Interactions between HIV/AIDS and the Environment
2003
•
2000
•
•
2008
2008
56
2007
International
Resources
Group (IRG)
Office of the
Senior Gender
Advisor- IUCN
International Union for
the Conservation of Nature
(IUCN) HIV/AIDS policy
(draft)
Hunter, LM,
et al.
Hunter, LM
et al.
Hunter, LM
et al.
Hemrich, G and
Topouzis, D
Impacts of climate change
on rural livelihoods in
Madagascar and the potential
for adaptation
“Locusts are now our
beef”: Adult mortality and
household dietary use of local
environmental resources in
rural South Africa
The environmental
dimensions of the HIV/
AIDS pandemic: A call for
scholarship and evidencebased intervention
Adult mortality and natural
resource use in rural South
Africa: Evidence from
the Agincourt Health and
Demographic Surveillance site
Multi-sectoral responses to
HIV/AIDS: Constraints and
opportunities for technical
co-operation
2008
•
Non-journal
policy paper
Non-journal
research/review
Journal research
Journal
commentary
Journal research
Journal policy
paper
Global
Madagascar
South Africa
Global
S. Africa
Sub-Saharan Africa
• Example of internal workplace HIV/AIDS policy of a
conservation agency
• Climate change leads to increased vulnerability (food/
water), increased pressures (e.g. distance to find fish),
increased variability of crop seasons.
• Formal assessment of households’ experience of climate
change
• “All dimensions of food security…are affected when HIV
is high”
• Mortality decreases food security, but not uniformly--the
gender of the dead and the household SES are important
• Dependence on the bush is not only a short-term coping
mechanism
• Introduction to a special issue on HIV and the
environment; good overview of the associated issues
• HIV and natural resource use
• Higher natural resource use/dependence among
mortality-affected, impoverished households
• “Selection, use, level of consumption, acquisition of
natural resources” important
• “Yes, there are definitely changes” in natural resource
consumption
• Need to shift away from HIV-specific programming
to broader development-based interventions, with
specifically HIV-focuses projects as needed, especially b/c
HIV is determined by same issues as underdevelopment
• Constraints: lack of multi-sectoral policy mandates from
donors, donor sectoral funding, sectoral government
agencies, lack of operational strategies
Appendix 1: Selected Annotated Bibliography (Documents marked with • indicate particularly rich sources of concepts, data, or references)
Interactions between HIV/AIDS and the Environment
2006
2004
2006
•
•
2007
57
2008 2007
Madagascar
Global
Journal case
study/review
Journal review
Lopez, P et al.
Lotze-Campen,
H and
Schellnhuber,
HJ
Linking protected area
management and HIV/AIDS
prevention--experiences from
Ankarafantsika National Park,
Madagascar
Climate impacts and
adaptation options in
agriculture: What we know and
what we don’t know
Kenya
Non-journal
research/review
Kiai, W et al.
Africa
S. Africa
Uganda
Zambia
Africa
The impact of HIV/AIDS on
the land issue in Kenya
Journal review
Journal research
Journal research
Journal research
Non-journal
policy paper
Kates, RW,
editor
Kaschula, SA
Kanyamurwa,
JM and Ampek
GT
Jayne, T et al.
Jayne, T et al.
The African Millennium
Villages
Wild foods and household
food security responses to
AIDS
Gender differentiation in
community responses to AIDS
in rural Uganda
Community-level impacts of
AIDS-related mortality: Panel
survey evidence from Zambia
Interactions between the
agricultural sector and the HIV
pandemic: Implications for
agricultural policy
2002
2005
•
• Climate change will have major food security and
agricultural effects
• Tourism may be affected, and may be a risk factor for
HIV transmission
• Mobile men increase transmission risk
• HIV presents new challenges to land policy and land
tenure systems in Kenya
• Widows and orphans have poor access to land
• Widow inheritance and land grabbing are common in Kenya
• Early review of outcomes of Millennium Villages Project;
suggests moderate levels of success
• Wild food use is affected by HIV-mortality
• Human resources losses, access to natural resources,
capital in male and female headed households differ
• Women are more vulnerable to affects of AIDS mortality-few assets and land access, more dependent on NGO system
• Loss of leaders leads to decrease in social cohesion
• HIV mortality affects the community as a whole, not only
the family of the deceased
• Deaths in communities with more education are more
devastating
• Higher income communities are protected from the
shocks associated with mortality
• Preparing the agriculture sector for the effects of HIV/AIDS
• Increased rural inequality, decrease in assets and
wealth leads to less capital-intensive agriculture, loss of
knowledge transfer
• Improved technology and a focus on productivity are needed
Appendix 1: Selected Annotated Bibliography (Documents marked with • indicate particularly rich sources of concepts, data, or references)
Interactions between HIV/AIDS and the Environment
2009
2009
•
2003
•
2009 2003 2008
no date
•
58
McMichael, AJ
et al.
Meier, B
Muchukuri, E
and FR Grenier
Global environmental change
and health: impacts, inequality,
and the health sector
HIV/AIDS and the environment:
What are the linkages? Impacts
on conservation capacity.
Ezemvelo KwaZulu Natal
Wildlife Human Resources,
presentation
Social determinants of health
and health inequalities in
Nakuru, Kenya
Murphy, LL
Mullins, D
McMichael, AJ
et al.
Climate change and human
health: risks and responses
AIDS and kitchen gardens:
Insights from a village in
Western Kenya
2009
Mainstreaming HIV/AIDS
into development: What it
can look like
McGarry, DK and
Shackleton, CM
Mauambeta,
DDC
Mamlin J, et al.
Is HIV jeopardizing
biodiversity?
HIV/AIDS mainstreaming in
conservation: the case of the
Wildlife and Environmental
Society of Malawi
Integrating nutrition support
for food-insecure patients and
their dependents into an HIV
care and treatment program
in western Kenya
Journal research
Non-journal
guideline or
toolkit
Journal research
Non-journal
presentation
Journal
commentary
Kenya
Southern Africa
Kenya
Tanzania
Global (focus on
Africa)
Global
• HIV/AIDS affects labor productivity, land tenure,
management, loss of traditional knowledge, natural resource
exploitation, increase in fallowed land
• AIDS increases kitchen garden use, which are repositories
of neglected species, increase vegetation cover, protect
watersheds, preserve germplasm (but could mine soil)
• Natural resource dependence is dependent on poverty, not
HIV-infection
• Guidelines for mainstreaming HIV into development
projects
• Access to water, food, waste management, housing, health
services, and transportation have an impact on health
• Example of internal workplace HIV/AIDS policy of a
conservation agency
• It’s impossible to separate environmental and health/
development goals or practices
• Overarching links between climate change and health;
climate change and infectious disease, policy implications
• High-HIV vulnerability children consumed more wild foods,
but impact on biodiversity is “unclear”
Primarily sub-Saharan
Africa, South Africa
Journal
commentary
Non-journal
review
• Good example of workplace HIV/AIDS Policy, internal
mainstreaming at a conservation organization
• Medical care is necessary but insufficient for addressing HIV
epidemic
• Food supplementation given at the household level to ART patient
• Food insecurity in 20-40% of patients enrolled in HIV care
• Challenges to food supplementation include funding,
dependency, sustainability, monitoring and evaluation
Malawi
Kenya
Non-journal case
study
Journal policy
paper
Appendix 1: Selected Annotated Bibliography (Documents marked with • indicate particularly rich sources of concepts, data, or references)
Interactions between HIV/AIDS and the Environment
2002
2008
•
2007
•
2009
2007
•
59
HIV/AIDS and conservation:
what can the conservation
sector do? World Wildlife
Fund, African Biodiversity
Collaborative Group,
International Union for the
Conservation of Nature,
presentation
2007
AIDS, women, land, and
natural resources in Africa
Oglethorpe, J
and Gelman, N
Oglethorpe, J
and Gelman, N
Oglethorpe, J
and Gelman, N
Ngwenya, BN
and Mosepele,
K
HIV/AIDS, artisanal fishing
and food security in the
Okavango Delta, Botswana
HIV/AIDS and the
environment: Impacts of
AIDS and ways to reduce
them: A fact sheet for the
conservation community
Myers, SS and
Patz, JA
Emerging threats to
human health from global
environmental change
Non-journal
presentation
Journal review
Non-journal
guideline or
toolkit
Journal research
Journal review
Africa
Africa
Global
Botswana
Global
• Broad review of HIV/AIDS issues for conservation
community, including lost capacity and workforce, as well
as land use and natural resources related effects
• Includes mainstreaming and intervention ideas
• Women, natural resource use, and HIV/AIDS
• Natural resources are a safety net
• Women don’t have time for sound natural resource
management
• Issues include: land-grabbing, property rights, loss of
traditional knowledge, resource depletion, medicinal plants
• Easier to poach because of HR decreases due to HIV
• Poverty and landlessness lead to increased risk behaviors
• Recommends livelihoods and female empowerment, and
programs for orphan and vulnerable children as interventions
• HIV impact mitigation for conservation organizations
• Human capacity, loss of investment in training, staff time,
diversion of money, morale down
• Natural resource use increased, loss of leadership, traditional
knowledge, effect on women, change in farming and land use
• HIV often spread through natural resource extraction (e.g.
fisheries, logging, remote conservation work)
• HIV/AIDS seriously impacts fishing activities, which are
a safety net for families. HIV/AIDS therefore affects food
security in fishing communities
• Fisheries sector policies generally neglect HIV/AIDS
• Major threats to human health from climate change
include increased infectious diseases and changing patterns
of these diseases, water and food scarcity, natural disasters,
and population displacement
Appendix 1: Selected Annotated Bibliography (Documents marked with • indicate particularly rich sources of concepts, data, or references)
Population, health, and
• Population Health and Environment (PHE) case studies
environment integration and
Non-journal
Kenya
Mwaura, F
in Kenya
cross-sectoral collaboration:
review
Kenya country level
• Many examples of PHE interventions
assessment report
Interactions between HIV/AIDS and the Environment
2008
no date
•
•
2008
2009
•
2003
Pisupati, B and
Warner, E
Quinlan, T
Biodiversity and the Millennium
Development Goals
The link between conservation and
HIV: what can be done?: Report of
a special side event, World Parks
Conference, Durban
Sztam, KA et al.
Macronutrient supplementation
and food prices in HIV treatment
2007
2006
•
•
60
2010
HIV/AIDS--the true tragedy of the
commons?: Exploring the effects
of HIV/AIDS on management and
use of local natural resources
Stillwaggon, E
AIDS and the ecology of poverty
2005
Ternström, I
Shackleton, CM
et al.
The importance of dry woodlands
and forests in rural livelihoods and
poverty alleviation in South Africa
2003
HIV/AIDS and the public sector
workforce: An action guide for
managers
Rau, B
Parker, DC et al.
Oglethorpe, J
et al.
A qualitative study of the impact
of HIV on agricultural households
in Southeastern Uganda
Healthy people, healthy
ecosystems: A manual on
integrating health and family
planning into conservation
projects
Non-journal
review
Journal review
Book
Journal case
study
Non-journal
guideline or
toolkit
Non-journal
workshop
Non-journal
review
Journal
research
Non-journal
guideline or
toolkit
Global
Global
Global
South Africa
Global
Africa
Global, but with
regional details
Uganda
Global
• HIV leads to increased natural resource use and a
disruption in social controls governing their use--eroding
social networks
• Malnutrition and HIV are a dual burden; standard of care
needed for food in HIV patients
• HIV-infection is determined by number of different factors,
not just risk behaviors
• Poverty and multi-disease burden are major risks for HIV
• Policy and interventions must be broadened beyond
behavior alone
• HIV has exacerbated people’s dependence on forests
• Forestry good contribute 4-30% of household income across
Southern Africa
• Forests integral to maintaining livelihoods and mitigating
extreme poverty
• Guidelines for creating and strengthening HIV prevention,
care, treatment, and support systems for government agencies
• Parks and reserves are vulnerable because of workforce
concerns
• Internal HIV/AIDS Policies at institutional level
• Biodiversity and climate change issues impact the
achievement of the MDGs
• HIV affects labor productivity, leads to decreased
household assets, worse land tenure, and change in
agricultural activities
• Guidelines for integrating population and health into
environment/conservation projects
Appendix 1: Selected Annotated Bibliography (Documents marked with • indicate particularly rich sources of concepts, data, or references)
Interactions between HIV/AIDS and the Environment
2005
•
2007
1999
•
2001
•
Topouzis, D,
Strategy Paper on HIV/AIDS
for East and Southern Africa
61
Torell, E et al.
UNEP,
UNAIDS
Villareal, M
and Holding
Anyonge, C
Climate change and AIDS: A
joint working paper
HIV/AIDS and the forestry
and wildlife sectors: Key
points towards a policy
discussion
Torell, E et al.
Guidelines for mitigating
the impacts of HIV/AIDS
on coastal biodiversity and
natural resource management
Examining the linkages
between AIDS and
biodiversity conservation in
coastal Tanzania
Topouzis, D and
du Guerny, J
Sustainable agricultural
rural development and
vulnerability to the HIV
epidemic
et al.
Thangata, PH
et al.
Predicted impact of HIV on
improved fallow adoption
and rural household food
security in Malawi
2006
2007
•
•
• HIV/AIDS and Climate Change “Complex” revolves
around food security, infectious disease, and governance/
conflict/poverty
• Multisectoral response to HIV is needed, and should
include forestry
• Collaboration on traditional medicines, agroforestry projects,
and nutrition education and skills building suggested
Global
Non-journal
policy paper
• HIV/AIDS leads to accelerated natural resource extraction,
decreased labor capacity, decreased management capacity,
and loss of traditional skills
• Many agriculture-sector specific intervention ideas
• HIV and fisheries and marine conservation areas
• HIV/AIDS leads to accelerated rate of natural resource
extraction (wood, meds, wildlife), decreased availability of labor
and management capacity, and loss of traditional knowledge
• Mobility (e.g. fishers) and seasonal migration increase risk,
as does tourism
• Protected areas decrease the natural resource use options
for vulnerable households
• Reducing gender inequality and poverty and providing
livelihoods mitigates effects
• HIV and the agricultural sector
• Includes how to integrate/mainstream HIV at all levels of
project, from inception to implementation
• Good overview of the gender aspects of the epidemic
• Rural impacts of HIV
• Rural migration of PLWHA means rural areas bear the
brunt of the epidemic’s economic affects
• HIV leads to loss of labor, decreased assets/income,
human resources losses at institutional level, increased
expenditures at household level, increased number of
dependents, and loss of knowledge
• Effect of HIV depends on gender of the affected family member
(male death more devastating in terms of food security)
• Movement to agro-forestry as an intervention to increase
food production
Primarily subSaharan Africa
Sub-Saharan Africa
coasts, Tanzania
Tanzania
Sub-Saharan Africa
Africa focus
Malawi
Non-journal
review
Non-journal
guideline or
toolkit
Journal research
Non-journal
policy paper
Non-journal
policy paper
Journal research
Appendix 1: Selected Annotated Bibliography (Documents marked with • indicate particularly rich sources of concepts, data, or references)
Interactions between HIV/AIDS and the Environment
2008
•
2004
2009
2007
2003
2008
62
The integration of support
for HIV/AIDS and livelihood
security: district level
institutional analysis in
southern Africa
HIV/AIDS impacts on
conservation capacity. USAID,
presentation
Measuring the impacts of
working-age adult mortality on
small-scale farm households
in Kenya
Food insufficiency is
associated with high-risk sexual
behavior among women in
Botswana and Swaziland
Strong association between
in-migration and HIV
prevalence in urban subSaharan Africa
Ziervogel, G
and Drimie, S
Zelothe, J
Yamano, T and
Jayne, TS
Weiser, SD,
et al.
Voeten, HA
et al.
Journal review
Non-journal
presentation
Journal research
Journal research
Journal research
Southern Africa
Tanzania
Kenya
Botswana and
Swaziland
Urban sub-Saharan
Africa
• Livelihoods interventions across the “AIDS timeline” are
presented
• Organizations are beginning to address food issues in an
environmentally conscious manner, but the are needs more
emphasis (e.g. seeds, new varietals, kitchen gardens)
•
• Example of internal workplace HIV/AIDS policy of a
conservation agency
• Effects of adult mortality on livelihoods are sensitive to gender
and position within the household of the deceased
• Household socio-economic status buffers effects of adult
mortality
• Effects of mortality are long lasting: did not decay over the three
year study-period
• Women who are food insecure are more likely to report
unprotected sex, low power in relationships
• Migration to urban settings leads to : increased sexual network
size, casual and commercial sex (spousal separation, weaker
social control)
• Conflict leads to rape, disruption of norms, collapse of system,
decreased access to condoms
Appendix 1: Selected Annotated Bibliography (Documents marked with • indicate particularly rich sources of concepts, data, or references)
Interactions between HIV/AIDS and the Environment
2008
•
IUCN Eastern and Southern Africa Regional Office
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Nairobi Kenya
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